# What is your opinion of pain management?



## RocketMedic (Jul 31, 2015)

"Patients only remember two things- were you nice, and did you make the pain stop"- a mentor.

One of the most common expectations of EMS is that we make the situation better, which to many people and patients means effective pain management as a component of care. Our ability to provide effective pain management (be it via non-pharmecutical or pharmaceutical means or a combination of the two) is one of the few things that differentiates us as a medical service from a transportation service in the minds of our customers. 

With that being said, what is your personal take on pain management and its importance in prehospital or out-of-hospital care? (Many of us have protocols allowing it, but it is our discretion to implement them, hence why it's a personal question). How did you come to this viewpoint?

Speaking of protocols, are you sufficiently empowered in your opinion to meet the expectations of your community, your patients and your receiving facility? Are your protocols inadequate, adequate or overly generous? What would you want to change?


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## Clare (Jul 31, 2015)

Pain is bad and should be relieved.  That's about it really.  Obviously you have to be sensible about it, I mean if somebody had low blood pressure then you just have to be more careful and give smaller doses or some fluid in addition to morphine or whatever, or better yet, use fentanyl! 

We have the following pain relief 

EMT:  Paracetamol, ibuprofen, tramadol, entonox, methoxyflurane
Paramedic:  All of the above plus morphine, fentanyl and lignocaine blocks
ICP:  All of the above plus ketamine and midazolam (noting midazolam has no pain relieving properties but can be used in severe muscle spasm etc)

If somebody is in pain they need pain relief until they are no longer need it.  I have spent lots of time on scene with people in pain getting them treated well enough otherwise we couldn't move them.  

I don't really like entonox only because the cylinder is not very practical to carry around in addition to everything else but it's not a problem once the pt is on the bed because you can put it between their legs or on the back if you sit the head end up.

I have never had a situation where it was not possible to relieve somebodies pain and I really cannot think of one either.  If they have low blood pressure give fluids and use small boluses of fentanyl, if they do not want morphine, use fentanyl, if they cannot have entonox, use methoxyflurane etc.

What is pain relief like elsewhere? I read that in US you don't have entonox.  I can't believe it why not? I mean, how do you give pain relief without it if you do not have morphine or the patient doesn't need it? Like somebody with a simple fracture who doesn't need morphine?


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## EpiEMS (Aug 1, 2015)

RocketMedic said:


> .Our ability to provide effective pain management (be it via non-pharmecutical or pharmaceutical means or a combination of the two) is one of the few things that differentiates us as a medical service from a transportation service in the minds of our customers.



100%, but when you look at your average BLS service in the bulk of the U.S., or even just your BLS unit in an ALS system, the BLS unit is limited to a few pain control measures, most of which won't really address the problem for quite a large number of common conditions.

If you look at the national scope for the EMT, pain control measures are:

 - Splinting (incl. traction splinting)
 - Ice & heat packs (this isn't *explicitly* in-scope, but there's no state protocol I'm aware of that would prohibit it)
 - The stare of life / soothing words
 - ALS intercept

I would argue that there are certainly pain control measures that could be introduced at the EMT-level, and certainly should be part of the national scope. For example, the addition of PO ibuprofen and/or PO acetaminophen, as some protocols have done, could be a beneficial intervention at low risk. Similarly, while entonox/nitrous isn't used in many systems, I can't see why adding it to the EMT scope (as it's already in the AEMT national scope) would be terribly harmful. On the more liberal end, how about pain control with...IN ketorolac?

This being said, for many BLS-level agencies, especially those where ALS and/or a hospital is a close drive, the value-add from the limited-risk pain control measures I suggest may be minimal. However, for those systems where the drive might be a bit longer, I can't imagine too much downside.

The U.S. is clearly behind the times -- pain is bad, and we should try and see what measures can be pushed down to BLS providers to relieve it. I would be wary of suggestions like introducing morphine autoinjectors in most systems, mainly owing to the logistical issues, but I can't imagine too much of a downside with sufficient OLMC direction.


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## cruiseforever (Aug 1, 2015)

I feel that pain should be treated aggressively.  The biggest issue our medical directors have is how to treat a chronic pain issue.  For the last few years we treated most pain fairly aggressive.  Now there is a big push to still treat acute pain aggresively, but to limit the use of medications to treat chronic pain. 

We can pick from, Morphine, Fentanyl, Dilaudid, Ketamine on standing orders. 

 Need to get med. control for Versed to help with pain management.  Still hoping to get that changed in the next year.  Had a procedure last year and was given Fentanyl and Versed.  What a wonderful combination.


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## NYBLS (Aug 1, 2015)

A subject I'm very interested in. For those posting what drugs you carry would you mind posting how much you carry? Curiosity on my part.


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## luke_31 (Aug 1, 2015)

We carry 20mg morphine, 2mg dilaudid, 10mg versed, and 10mg Valium. We can administer 10mg morphine, 2mg dilaudid without orders, and can administer either the verses or Valium for seizures without orders and have to call for sedation. But we also carry haldol for combative patients


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## chaz90 (Aug 1, 2015)

Our pain management policy is fairly constrained based on what we carry, and our pharmacological choices are extremely limited. We carry 400 mcg Fentanyl and 10 mg Versed. That's it. There have been discussions about getting Ketamine, but I've heard no rumors of anything else like Ketorolac or any alternative opioids or benzos. 

Some variety of PO analgesic wouldn't be the worst idea, even though I understand the argument that if the pain is that minor it likely doesn't need intervention by EMS. I would like to be able to offer something to our patients that have pain that doesn't reach the level of needing narcotics but could still benefit from some type of relief. It would also be nice to have something to administer to patients that really don't want opioids for whatever reason. 

If we only had to carry one opioid analgesic I'm certain Fentanyl would be the one to choose, but I really believe we would benefit from having some Dilaudid to use as an alternative during some of our extremely long transports. Multiple administrations of small doses of Fentanyl during an hour long transport across country roads can get tiresome.


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## Clare (Aug 1, 2015)

We carry paracetamol, ibuprofen and tramadol tablets.  I do not know the exact number but probably 100 of each.  We also have paracetamol liquid in a container you fit the syringe into the top and draw it up so there is no mess, its awesome.  

Entonox is a single cylinder that is the same size as portable oxygen, i think from memory its a couple hundred litres.  Methoxyflurane one kit is carried in the first response bag and one in the ambulance.  

Each officer carries 30 mg of morphine, 200 mcg of fentanyl and ICPs also carry 400 mg of ketamine.


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## cruiseforever (Aug 1, 2015)

NYBLS said:


> A subject I'm very interested in. For those posting what drugs you carry would you mind posting how much you carry? Curiosity on my part.


 
Depends on the area that I am working in.  But the most common amounts are:  Morphine 40 mg, Fentanyl 200 mcg, Dialudid 4 mg, Ketamine 1000 mg, Versed 40 mg.

For trauma we have no limits on the amount of Morphine, Fentanyl is 200 mcg, Dialudid is 2 mg, Ketamine is a max of 50 mg, need to call med control if we want Versed or more Ketamine.

Cardiac we are limited to 10 mg morphine without med control.

Other medical conditions we can default to the trauma doses.


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## teedubbyaw (Aug 1, 2015)

Unfortunately, it's hard to please everyone when Fentanyl is the only decent pain management medication we carry.


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## Carlos Danger (Aug 1, 2015)

Honestly, I'd be happy with nothing but fentanyl in the field. It is hands down the most useful analgesic for prehospital use. More bang for your buck than anything else.

Ketamine is a good option to have available but IMO is not better than fentanyl in 95% of cases of severe pain.

Dilaudid is a great drug but it's long onset makes it hard to titrate and it's long duration and potent respiratory depressant effects means that accidentally giving too much can cause problems. So it's utility is limited primarily to long transports, but even then I'd probably rather use fentanyl most of the time.

Morphine is just a lousy drug compared to fentanyl or hydromorphone. All the downsides of dilaudid magnified - plus several downsides that don't exist with dilaudid. I never use morphine for anything.

The potent fentanyl analogues (sufentanil, alfentanil) are great but not better than fentanyl for routine use. Alfenta has some interesting, almost neurolept anesthetic-like properties that are useful in some settings.

Ketorolac is a great adjunct to opioids but alone is only really effective in certain types of mild-moderate pain. Importantly, it is contraindicated (or relatively so) in many patients - basically in anyone sick, you should think twice about using it. This makes it not a great drug for prehospital use, IMO.

IV acetaminophen, like ketorolac, only works as an adjunct to opioids if pain is severe. It is a good option in less severe pain, but it has a relatively long onset time. It is also currently only available in glass bottles.

PO NSAIDs have too long an onset time to be useful in the prehospital setting, and are only useful in certain types of pain.

Gabapentin, pregabalin, tramadol, phenytoin, and the other reputake inhibitors and antiepileptics are primarily used in the management of chronic pain and may have some role in certain types of acute pain, but as of now are not appropriate for prehospital use.

Certain miscellaneous adjuncts like esmolol, dexamethasone, lidocaine, magnesium, clonidine, antihistamines, etc. can probably be useful in some situations but require a more thorough understanding of pain physiology and pharmacology, and have never been experimented with in the ED or EMS settings, that I am aware of.

Dexmedetomidine is a great drug that I loved using (don't have it where I am now) but I don't foresee it becoming common in the prehospital arena anytime soon.

You hear a lot of paramedics talk about using benzos as an adjunct to opioids in severe pain but I don't think that's a great practice. You can read about anxiety aggravating nociception in some patients but generally they are separate problems, so if someone is really freaking out despite a decent dose of opioids, versed might be a good option but understand you are using the versed to treat their anxiety, not to potentiate the opioid. Generally, more opioid is the answer.

So, IMO fentanyl is really where it's at. Dilaudid and ketamine are good to have in the drug box as options, but I'd rarely use them. That's just my 2 cents.


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## teedubbyaw (Aug 1, 2015)

I agree that it's good for our use, but I'll be happy when Ketamine comes into our pain management protocols next year.


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## MonkeyArrow (Aug 1, 2015)

Remi said:


> Certain miscellaneous adjuncts like *esmolol*, dexamethasone, lidocaine, clonidine, antihistamines, etc. can probably be useful in some situations but require a more thorough understanding of pain physiology and pharmacology.


Can you explain esmolol? I thought it was a beta blocker used mostly in cases of aortic dissection.

Also, I don't really understand why people are carrying dilaudid on ambulances. Hell, our ED medical director doesn't like patients being given hydromorphone and the trend is really to move away from it as soon as possible post-op, so I really don't understand why people carry it pre-hospitally. It is, as I understand, one of the most potent analgesics, with a long duration and not able to be titrated. Why someone would push something so strong pre-hospitally when you can just give fent (for short transports) or set up a fent drip (for longer transports) is beyond me.


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## Carlos Danger (Aug 1, 2015)

MonkeyArrow said:


> Can you explain esmolol? I thought it was a beta blocker used mostly in cases of aortic dissection.



There are several theories, ranging from a reduction of hepatic opioid metabolism to activation of g-proteins that are involved in nociception to making the blood-brain barrier more permeable to opioids, to a central opioid-like mechanism involving inhibitory neurotransmitters in the spinal cord.

http://journals.lww.com/_layouts/OAKS.Journals/ePDF.aspx
http://www.aana.com/newsandjournal/20102019/060115roleesmololperianalgesia.pdf



MonkeyArrow said:


> Also, I don't really understand why people are carrying dilaudid on ambulances. Hell, our ED medical director doesn't like patients being given hydromorphone and the trend is really to move away from it as soon as possible post-op, so I really don't understand why people carry it pre-hospitally. It is, as I understand, one of the most potent analgesics, with a long duration and not able to be titrated. Why someone would push something so strong pre-hospitally when you can just give fent (for short transports) or set up a fent drip (for longer transports) is beyond me.



Dilaudid is a great drug and I think it definitely has a role prehospital, but you do need to be careful with it - it is certainly less forgiving than fentanyl.


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## Clare (Aug 1, 2015)

Remi said:


> Honestly, I'd be happy with nothing but fentanyl in the field



Coming from an anaesthetist I am quite surprised by this given it's the medical speciality who deal most with pain (both acute and chronic).  I am sure not all of your patients get fentanyl and nothing else in the hospital for their acute pain so why should it be any different prehospital? 

What about entonox or methoxyflurane?  Entonox is spectacular for patients who only have moderate pain and who don't need morphine or fentanyl.  If you can't have entonox for whatever reason then there's methoxyflurane as an alternate.  I have personally never used methoxyflurane but it's used by every ambulance service in Australia so it must be doing something right.  

The addition of tramadol oral has been great in the ambulance, again I've seen amazing results with it.  Quite a few people with pain that would have otherwise received morphine can be managed with paracetamol, ibuprofen and tramadol in combination with entonox.  It's great for double EMT crews from the volunteer stations who might be a long way from hospital or backup as well.  Gives them something a bit stronger. 

Paracetamol and ibuprofen in combination are great for mild pain, especially in kids.


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## Carlos Danger (Aug 1, 2015)

Clare said:


> Coming from an anaesthetist I am quite surprised by this given it's the medical speciality who deal most with pain (both acute and chronic).  I am sure not all of your patients get fentanyl and nothing else in the hospital for their acute pain so why should it be any different prehospital?
> 
> What about entonox or methoxyflurane?  Entonox is spectacular for patients who only have moderate pain and who don't need morphine or fentanyl.  If you can't have entonox for whatever reason then there's methoxyflurane as an alternate.  I have personally never used methoxyflurane but it's used by every ambulance service in Australia so it must be doing something right.
> 
> ...



First, I am very much of the K.I.S.S. school of thinking. We can do things lots of different ways but I prefer the simplest in almost every case. You just don't need a ton of different drugs.

A patient with acute pain in the prehospital setting is a very different animal than someone having a painful procedure done, or a post-op patient, or an ICU patient. Because they are different, they get managed differently, with different drugs. There are lots of things that I do in the OR and PACU that are simply not relevant to the prehospital setting. For instance, we use gabapentin pre-op for some OR cases, and clonidine in nerve blocks. That doesn't mean those are necessarily good drugs to give in an ambulance.

Fentanyl is potent, predictable, fast, forgiving, titratable, and has few side effects.....much more so than ketamine or the longer lasting opioids (morphine, hydromorphone, meperidine) or anything that can be given PO. It is the perfect EMS analgesic.

Entonox and methoxyflurane are not widely available in the US. I have never used either, nor do I remember them even being mentioned at any point in my training, either as a paramedic or CRNA.

Tramadol is a weak opioid and reuptake inhibitor. The serotonergic effects take several doses to become pronounced, so they are not a factor in the prehospital setting. All you are left with with is a weak opioid that takes at least 30 minutes to even start working, and an hour to take full effect. I don't see that as having any role in the prehospital setting, where my goal is to get pain under control _now_. Plus, with antidepressants being so commonly used in the US, there is polypharmacy to consider in giving a serotonergic and norepinephrinergic drug. I'm not sure how it is where you live, but consumers of EMS services in the US tend to be on lots of meds.

For mild pain, sure, ibuprofen and/or acetaminophen are great. As an adjunct to opioids, I don't see their effects being all that valuable in the field, owing largely, again, to their long onset time.

Edit: I just realized you probably have IV tramadol. I have never used or even seen it; only the PO version is common here.


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## EMTinCT (Aug 2, 2015)

Had a PT who was trapped in a vehicle from a head on collision. She was screaming in horrible pain due to her legs being crushed and the wreckage from the car pinning them. We're BLS and couldn't do anything for the pain during the 1hr it took for the FD to cut her out. Even after we got her on the ambulance it took another 40 minutes to get to the closest ER which isn't a trauma facility but at least they have a helicopter landing pad. No ALS service is available to us as we're that far in the boonies. If you had been an EMS medical director and in such an accident I guess you'd become a proponent of BLS-level pain control.


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## Flying (Aug 2, 2015)

EMTinCT said:


> Had a PT who was trapped in a vehicle from a head on collision. She was screaming in horrible pain due to her legs being crushed and the wreckage from the car pinning them. We're BLS and couldn't do anything for the pain during the 1hr it took for the FD to cut her out. Even after we got her on the ambulance it took another 40 minutes to get to the closest ER which isn't a trauma facility but at least they have a helicopter landing pad. No ALS service is available to us as we're that far in the boonies. If you had been an EMS medical director and in such an accident I guess you'd become a proponent of BLS-level pain control.


As much as I would like to be able to provide methoxyflurane to patients, a better case could probably be made for paying for an ALS intercept service in your area.


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## Tigger (Aug 2, 2015)

I would like to see something to bridge the gap between opioid analgesia and positioning measures. Our transport times are sometimes long, and realistically the patient with minor to moderate pain is not going to be medicated in the ED quickly, so I see some use in medications with a longer onset. Toradol works for many patients, but as noted is not often a great choice for the chronically ill. Nitronox exists and is reasonably safe, but is big/bulky and expensive. 

Fentanyl is our go to here (400mcg onboard, 1-3mcg/kg with no max dose). We also carry Ketamine (500mg on board), and Morphine (40mg). Versed (10mg) and Valium (20mg) can be given for spasm and as an anoxilytic, though our medical director prefers Ketamine be used first.


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## EMTinCT (Aug 2, 2015)

Flying said:


> As much as I would like to be able to provide methoxyflurane to patients, a better case could probably be made for paying for an ALS intercept service in your area.


That's the thing, we are an all-volunteer department with fewer than 200 calls a year. Paying for ALS intercept isn't possible. We barely have enough money to keep diesel in the ambulance so paying for a medic can't happen. In addition there is no ALS service for just over 50 miles so even if we paid for it the timing makes it impossible.

These are the realities of rural, volunteer EMS that ought to change how things are done and influence how decisions are made. At least that's what grandma says.


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## NomadicMedic (Aug 2, 2015)

Wow. Where in CT is this? It seems as though I recall and over abundance of medics. (At least in eastern CT)


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## EMTinCT (Aug 2, 2015)

DEmedic said:


> Wow. Where in CT is this? It seems as though I recall and over abundance of medics. (At least in eastern CT)



Not in CT. Where I lived in Montana a few years back.


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## johnrsemt (Aug 3, 2015)

With an hour to extricate why didn't you call for a helicopter?  I have seen Helicopter services come in and give pain meds in a case like that and then leave for the patient to be transported by ground.  Doesn't happen much, but does.  Also seen the flight medic ride in on the ambulance with the patient.
And your service does not pay for the medic, the patient does (and if they don't pay then the ALS service eats it, just like your service eats it if the patient doesn't pay for your services).  At least that is the way that all insurance companies do it in the US.

We carry 20mg of Morphine and 200mcg of Fentanyl;  and can give all of either without contacting a doc;  but we have minumum of 45 minute transport to closest hospital.   and I have actually had 95 minute transport to closest  hospital.  Level II and Level I hospitals are minimum of 80 minutes away.


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## johnrsemt (Aug 3, 2015)

and opinion of pain management is that prehospital it is NOT done enough.   Proven time and again that people in less pain heal faster.  

With a lot of patients we can't do much else for them, why make them hurt more.

In my old service I had a medic brag that in 12 years she had NEVER given Pain meds;  then in the next sentence she told me that if she was ever hurt she wanted me to take her to the hospital.
  One day she called for me to intercept for pain management (she had an employee that fell down the stairs and hurt her leg).,  I thought it was cause she started transporting without grabbing narcs;  no she just refused to push pain meds, but didn't want to hear the patient scream anymore.


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## Clare (Aug 3, 2015)

johnrsemt said:


> In my old service I had a medic brag that in 12 years she had NEVER given Pain meds;  then in the next sentence she told me that if she was ever hurt she wanted me to take her to the hospital.
> One day she called for me to intercept for pain management (she had an employee that fell down the stairs and hurt her leg).,  I thought it was cause she started transporting without grabbing narcs;  no she just refused to push pain meds, but didn't want to hear the patient scream anymore.



Surely you are joking? That is absolutely abhorrent and disgusting.  I cannot accept that you are not somehow joking honestly.  

If you are not joking, then I am at a loss to understand how this was not identified by clinical support or auditing processes, or better yet, by voluminous patient complaints to either your service individually, to whatever you call the Ministry of Health or patient advocacy people in the US.  

I also presume if you are not joking that you made a very loud official complaint to both your clinical standards or development function and whatever regulatory authority is responsible for ambulance personnel in the US because that is nothing but negligence.  Absolute, complete and unequivocal negligence and failure to provide care of an appropriate standard.  And if you did not, then you are just as negligent.  

I do not think anything I have seen or heard in my time in the ambulance service makes me more disgusted.  And I have seen some pretty horrific things.


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## Underoath87 (Aug 3, 2015)

We're in the process of switching to fentanyl from morphine and dilaudid, but many medics are unfortunately under the impression that it is weak and often doesn't help much, since we are limited to 100 mcg per pt.
For IV: 1 mcg/kg (max of 50 mcg), can be repeated once after 5 minutes. 
IM or IN: 2 mcg/kg, max of 100 mcg. 

We have ketamine, but can only use it for RSI.


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## chaz90 (Aug 3, 2015)

Underoath87 said:


> We're in the process of switching to fentanyl from morphine and dilaudid, but many medics are unfortunately under the impression that it is weak and often doesn't help much, since we are limited to 100 mcg per pt.
> For IV: 1 mcg/kg (max of 50 mcg), can be repeated once after 5 minutes.
> IM or IN: 2 mcg/kg, max of 100 mcg.
> 
> We have ketamine, but can only use it for RSI.


There's a fair number of patients that I administer more than 50 mcg Fentanyl, even on the initial dose. Restricting the entire dose to a max of 100 mcg is pretty ridiculous too. It's funny that your protocols are so strict regarding Fentanyl when you're coming away from Morphine and Dilaudid. Really, fentanyl is much easier to manage and has a better side effect profile than those two. What were your dosing guidelines for Morphine and Dilaudid?


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## Underoath87 (Aug 3, 2015)

chaz90 said:


> There's a fair number of patients that I administer more than 50 mcg Fentanyl, even on the initial dose. Restricting the entire dose to a max of 100 mcg is pretty ridiculous too. It's funny that your protocols are so strict regarding Fentanyl when you're coming away from Morphine and Dilaudid. Really, fentanyl is much easier to manage and has a better side effect profile than those two. What were your dosing guidelines for Morphine and Dilaudid?



Max of 2 mg for dilaudid and 10 mg for morphine.  But they could receive both.  So obviously 100 mcg of fentanyl seems weak by comparison.


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## EMTinCT (Aug 3, 2015)

johnrsemt said:


> With an hour to extricate why didn't you call for a helicopter?  I have seen Helicopter services come in and give pain meds in a case like that and then leave for the patient to be transported by ground.  Doesn't happen much, but does.  Also seen the flight medic ride in on the ambulance with the patient.
> And your service does not pay for the medic, the patient does (and if they don't pay then the ALS service eats it, just like your service eats it if the patient doesn't pay for your services).  At least that is the way that all insurance companies do it in the US.
> 
> We carry 20mg of Morphine and 200mcg of Fentanyl;  and can give all of either without contacting a doc;  but we have minumum of 45 minute transport to closest hospital.   and I have actually had 95 minute transport to closest  hospital.  Level II and Level I hospitals are minimum of 80 minutes away.



We did but there was no landing zone for 10 miles.


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## sir.shocksalot (Aug 3, 2015)

Clare said:


> I do not think anything I have seen or heard in my time in the ambulance service makes me more disgusted.  And I have seen some pretty horrific things.


Here in the good ol' US of A our EMS systems are so fractured with next to no oversight that some EMS providers can almost literally get away with murder. Taking action on a provider's certification varies by state and, in my experience, occurs very infrequently. It's not like filing a grievance against a doc or a nurse. And even revoking a provider's certification in one state won't necessarily preclude them from working in EMS in another state. Unfortunately, there is no mandatory federal oversight for EMS providers, no mandatory reporting of care, treatments, transport, or anything really. The onus is upon each agency and their medical director to police the care (or lack thereof) given by providers. EMS as a whole in the US is an embarrassment compared to most other places. The agencies that are doing it right aren't any different on paper than the ones that give shoddy care with outdated protocols or a complete lack of necessary equipment. Maybe one day we can have mandatory reporting and quality measures tied to medicare/medicaid reimbursement like every other healthcare profession in the country.



Underoath87 said:


> We're in the process of switching to fentanyl from morphine and dilaudid, but many medics are unfortunately under the impression that it is weak and often doesn't help much, since we are limited to 100 mcg per pt.
> For IV: 1 mcg/kg (max of 50 mcg), can be repeated once after 5 minutes.
> IM or IN: 2 mcg/kg, max of 100 mcg.
> 
> We have ketamine, but can only use it for RSI.


100 mcg just doesn't cut it with Fentanyl. Doses can easily end up going well over 400mcg before getting control of some pain. Sometimes Fentanyl has to be mixed with Versed or valium before pain starts to become manageable. It's all really patient dependent to the point that medical directors need to give a lot of latitude to paramedics to treat pain with whatever doses and mixes they need to get the job done. It's sort of sad that you can RSI but not give Fentanyl in reasonable amounts. Ketamine is also very effective for pain in low doses, there is quite a few agencies in CO using it for pain along with the military. You should see if you can sell your medical director on the idea by giving him a few studies showing it's safety and efficacy.


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## TRSpeed (Aug 3, 2015)

Kern County Fent standing order of max 200mcg. 20MG Morphine . We can call for more. Carry 800mcg Fent, 40mg MS, 30mg Vallium, 16mg Versed just got rid of Ativan :/.


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## Carlos Danger (Aug 4, 2015)

sir.shocksalot said:


> 100 mcg just doesn't cut it with Fentanyl. Doses can easily end up going well over 400mcg before getting control of some pain. Sometimes Fentanyl has to be mixed with Versed or valium before pain starts to become manageable. It's all really patient dependent to the point that medical directors need to give a lot of latitude to paramedics to treat pain with whatever doses and mixes they need to get the job done. It's sort of sad that you can RSI but not give Fentanyl in reasonable amounts. Ketamine is also very effective for pain in low doses, there is quite a few agencies in CO using it for pain along with the military. You should see if you can sell your medical director on the idea by giving him a few studies showing it's safety and efficacy.



I agree that arbitrary limits are not in the best interest of patients. On the other hand, neither is giving tons of narcs just so you can brag about how "aggressive" you are with pain management. Which is not unheard of in some EMS circles - we all know the type. So while I don't like seeing "hard limits" in terms of max doses, I also don't think it's unreasonable to have to call OLMC once you get above a certain dose.

I would not say that "100 mcg doesn't cut it with fentanyl". It depends on the severity of pain and other factors, of course. 50% TBSA burns? Yeah, there's a good chance you'll need a lot more than 100 mcg. Chronic pain patient who already takes lots of opioid and now has a hip fracture from a fall? Might as well draw up a couple vials from the start. But outliers like those aside, you don't usually need a _ton_ of fentanyl. If you are routinely going over 2, definitely 3 mcg/kg or so in order to manage "typical" pain, I'd have an independent lab do a QC on the potency of your fent. Either that, or re-evaluate what specifically you are trying to achieve with your analgesia.


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## evantheEMT (Oct 25, 2015)

Depends what als has just because you give pain meds onscene doesn't mean  it will help them. I know some places carry the least amount that really doesn't help.


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## Tigger (Oct 25, 2015)

evantheEMT said:


> Depends what als has just because you give pain meds onscene doesn't mean  it will help them. I know some places carry the least amount that really doesn't help.


It will certainly help more than giving none. Your second sentence does not make sense.


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## evantheEMT (Oct 25, 2015)

Tigger said:


> It will certainly help more than giving none. Your second sentence does not make sense.


Of course it does they carry so little that there's no point to even given it.


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## TransportJockey (Oct 25, 2015)

evantheEMT said:


> Of course it does they carry so little that there's no point to even given it.


Granted, most of my time is in rural areas, but I haven't seen a service carry less than 200mcg Fent and/or 20mg MS (plus my last rural 911 job before this we carried 400mcg Fent, 40mg MS, 10mg Dilaudid, and quite a bit of Demerol (depending how much was on backorder)). 200 and 20 is a perfectly good amount to carry. I've never seen a service, even urban services, carry 'too little'


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## DesertMedic66 (Oct 25, 2015)

I quite often max out standing orders for pain medications on our hip fracture patients. A simple call to the hospital for additional pain meds is a very simple thing to do.


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## NomadicMedic (Oct 25, 2015)

evantheEMT said:


> Of course it does they carry so little that there's no point to even given it.



This is something I hear from old medics who don't want to crack open the seal on their drug box. Sounds like a line of crap that the OP took as gospel.


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## Tigger (Oct 25, 2015)

evantheEMT said:


> Of course it does they carry so little that there's no point to even given it.


Grammatically it was impossible to understand. And no service carries to little, a single vial of fentanyl is often more than enough for one patient. You do not know what you speak.


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## H33 (Oct 27, 2015)

Much to my sorrow while our state allows pain control by several means it does not require it, so alas we do not carry it. It's quite nice when we average 60 mile 911 transports.. ma'am bite down on the leather strap and curse if you feel the need..


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## chaz90 (Oct 28, 2015)

H33 said:


> Much to my sorrow while our state allows pain control by several means it does not require it, so alas we do not carry it. It's quite nice when we average 60 mile 911 transports.. ma'am bite down on the leather strap and curse if you feel the need..


Wow. Are you an ALS service? Do you not have any ALS intercept services available?


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## H33 (Oct 28, 2015)

Paramedic, ALS service, and our only option for pain meds is the whirly bird.


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## NomadicMedic (Oct 28, 2015)

Really? Where is this?


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## chaz90 (Oct 28, 2015)

H33 said:


> Paramedic, ALS service, and our only option for pain meds is the whirly bird.


Maybe I'm naive, but I'm blown away that there's a paramedic level service in the US today that doesn't carry anything for pain management. How utterly unjustifiable and barbaric of your medical director and admin.


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## H33 (Oct 28, 2015)

chaz90 said:


> Maybe I'm naive, but I'm blown away that there's a paramedic level service in the US today that doesn't carry anything for pain management. How utterly unjustifiable and barbaric of your medical director and admin.


I don't disagree.. but true it is.. south alabama 12 trucks 5 counties. 10 of which ALS


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## Tigger (Oct 28, 2015)

chaz90 said:


> Maybe I'm naive, but I'm blown away that there's a paramedic level service in the US today that doesn't carry anything for pain management. How utterly unjustifiable and barbaric of your medical director and admin.


There are several Albany area services that do the same. It's not a required medication, so they don't carry it and therefore avoid "regulatory" issues.


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## CentralCalEMT (Oct 28, 2015)

To me, pain management is an essential part of being a paramedic. It blows me away how many "old school" paramedics believe that pain medication should only be used in the most extreme cases. In my area, all we have is Fentanyl. When we switched from morphine we also got a "severe pain management" protocol which gives us the right to give pain medications as standing orders in any situation where there is significant pain and the patient has a stable BP, and no ALOC. Still some paramedics say they are not "the candy man" and still do not give pain medication when it is warranted. It embarrasses me as a paramedic, when I see another medic bring a patient in who is writing in pain and is telling them "there is nothing they can do for them until the doctor sees them that they do not carry pain medications". Now that I am a field preceptor, I try and instill in the paramedic student that as paramedics we will not save many lives at all, but we can relieve human suffering and that is extremely important. There is NO reason to withhold pain medication or any medication that relieves suffering (Zofran, etc.) to any patient who needs it based on the paramedic's personal opinion.


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## medic5678 (Oct 28, 2015)

It had better be real and severe before I'm happy giving anything.   Absent any obvious injury.. the more drama, the less real I think it is.  They start saying they're allergic to everything except what they want?  My Bull Sh*t detector goes off!


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## Carlos Danger (Oct 28, 2015)

CentralCalEMT said:


> It blows me away how many "old school" paramedics believe that pain medication should only be used in the most extreme cases.



Us old school guys were trained that way.

Not that that's an excuse for poor care, but the attitude towards prehospital analgesia has changed dramatically in just the past 5-10 years.


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## CentralCalEMT (Oct 28, 2015)

Remi said:


> Us old school guys were trained that way.
> 
> Not that that's an excuse for poor care, but the attitude towards prehospital analgesia has changed dramatically in just the past 5-10 years.



That does make sense. Unfortunately, many people who are in this field, just get their 48 or 72 hours of CE every two years and do not actually keep up with recent trends and ideas.


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## TRSpeed (Oct 28, 2015)

Heck, during my recent internship I'm glad my got my preceptor and I agreed on many things and treating our patients pain was ne of them. I belive we filled out almost a whole narc log sheet in a little more than 500hrs.  Many compliments were received and happier more pleasant patient transports followed ..it kills me to see a pt suffering in pain and the medic just ignoring it because "i only give meds to obvious fractures" . It's embarrassing to watch. Unfortunately,  I believe alot of it also has to do with more paperwork being required when narcs are used.

Needless to say, I'm glad we have a new progressive and involved medical director which allows to have a agressive pain management protocol.


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## CALEMT (Oct 28, 2015)

TRSpeed said:


> Unfortunately, I believe alot of it also has to do with more paperwork being required when narcs are used.



Thats what it boils down to most of the time it seems. Now granted I'm not the one writing the PCR and pushing the narcs, but not to give pain meds just because it takes longer to finish your PCR is total bull **** in my book.


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## DesertMedic66 (Oct 28, 2015)

CALEMT said:


> Thats what it boils down to most of the time it seems. Now granted I'm not the one writing the PCR and pushing the narcs, but not to give pain meds just because it takes longer to finish your PCR is total bull **** in my book.


It's not a whole lot more paperwork in all honestly. 

Per protocol we are only able to give pain meds for extremity trauma. If it's anything aside from that we have to contact base to get an order. One of our hospitals is famous for not giving us orders (that may change due to their new EMS medical director) so our way around this is we contact another hospital who will give us orders and then have the hospital contact the hospital we are transporting to haha


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## CALEMT (Oct 28, 2015)

DesertMedic66 said:


> It's not a whole lot more paperwork in all honestly.
> 
> Per protocol we are only able to give pain meds for extremity trauma. If it's anything aside from that we have to contact base to get an order. One of our hospitals is famous for not giving us orders (that may change due to their new EMS medical director) so our way around this is we contact another hospital who will give us orders and then have the hospital contact the hospital we are transporting to haha



In all reality no its not that much more paperwork. Not saying anyone I've worked with does it, but you do hear of people doing it. 

I think I know which hospital you're talking about. Its been awhile since I've seen fent pushed and don't exactly remember which hospital it is haha. But thats clever clever calling another hospital to get orders. Kinda like going to mom when dad says no haha.


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## MonkeyArrow (Oct 28, 2015)

DesertMedic66 said:


> It's not a whole lot more paperwork in all honestly.
> 
> Per protocol we are only able to give pain meds for extremity trauma. If it's anything aside from that we have to contact base to get an order. One of our hospitals is famous for not giving us orders (that may change due to their new EMS medical director) so our way around this is we contact another hospital who will give us orders and then have the hospital contact the hospital we are transporting to haha


If you contact a hospital for base orders, don't you have to transport to that hospital?

Aside from that, I feel like especially in an urban environment, and working in an ED where I can see the other side of the coin, I don't see the need for aggressive pain management with 10-15 minute transports. Likely by the time the med actually starts making a difference, you're pretty close to the hospital and giving things pre-hospitally messes up the ED "flow" if you will. For example, we do not give narcotics in the ED unless you are either getting admitted or have a ride home. If you are driving home, no candy for you. Most medics don't really think about that. Also, having the advantage of seeing a lot of our patient's EMR, you feel a lot more jaded when you see someone with 10/10 pain acute onset lower back pain, but they've been at the ED every month and have had 30 of hydrocodone filled a week ago.


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## DesertMedic66 (Oct 28, 2015)

CALEMT said:


> In all reality no its not that much more paperwork. Not saying anyone I've worked with does it, but you do hear of people doing it.
> 
> I think I know which hospital you're talking about. Its been awhile since I've seen fent pushed and don't exactly remember which hospital it is haha. But thats clever clever calling another hospital to get orders. Kinda like going to mom when dad says no haha.


EMC and thats exactly what its like. Only if you get denied orders from one hospital it's going to be a huge problem if you call other one. So to avoid that we just skip mom and go directly to dad.



MonkeyArrow said:


> If you contact a hospital for base orders, don't you have to transport to that hospital?
> 
> Aside from that, I feel like especially in an urban environment, and working in an ED where I can see the other side of the coin, I don't see the need for aggressive pain management with 10-15 minute transports. Likely by the time the med actually starts making a difference, you're pretty close to the hospital and giving things pre-hospitally messes up the ED "flow" if you will. For example, we do not give narcotics in the ED unless you are either getting admitted or have a ride home. If you are driving home, no candy for you. Most medics don't really think about that. Also, having the advantage of seeing a lot of our patient's EMR, you feel a lot more jaded when you see someone with 10/10 pain acute onset lower back pain, but they've been at the ED every month and have had 30 of hydrocodone filled a week ago.


Nope. We can transport to whatever hospital we want to. The base hospital we contacted will make contact with the hospital we are transporting to and let them know whats going on.

Fentanyl has almost an immediate onset time when given IV and is at full strength within minutes of giving it, so it does help in the short transport times. Our EDs work a little differently here. Our EDs give out narcotics almost immediately after an IV is started for patients in pain. During my clinical time for medic school the process in the ED was: Vitals, Doc assessment, IV, bloods, pain management, CT scans (or other scans and treatments). It makes no difference if the patient is going to be admitted or not (Kidney stones are very painful and hardly any of these patients are admitted). Our hospitals and EMS agency views pain as an additional vital sign. The goal is to bring the patients pain down to a bearable limit or better yet to have the patient in zero pain.


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## Tigger (Oct 28, 2015)

MonkeyArrow said:


> If you contact a hospital for base orders, don't you have to transport to that hospital?
> 
> Aside from that, I feel like especially in an urban environment, and working in an ED where I can see the other side of the coin, I don't see the need for aggressive pain management with 10-15 minute transports. Likely by the time the med actually starts making a difference, you're pretty close to the hospital and giving things pre-hospitally messes up the ED "flow" if you will. For example, we do not give narcotics in the ED unless you are either getting admitted or have a ride home. If you are driving home, no candy for you. Most medics don't really think about that. Also, having the advantage of seeing a lot of our patient's EMR, you feel a lot more jaded when you see someone with 10/10 pain acute onset lower back pain, but they've been at the ED every month and have had 30 of hydrocodone filled a week ago.


The 90s called and they would like their ED back.

But actually. Did you ever work on an ambulance? The transport is often not the issue, getting the patient from where they lie to the cot is. We aren't going to not medicate someone just because we're only 10 minutes from the hospital. There are so many more considerations than that. Also, IV fentanyl has reasonably quick onset time and Ketamine is nearly instantaneous. 

We also get our orders from one hospital network but transport to others as our medical control comes out of that network.


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## NomadicMedic (Oct 28, 2015)

Well, I guess it depends on where you are. At the service I'm working at PRN, giving ANY medication is a huge pain in the balls. Any Med, not just narcs. Even zofran.

If you open a message bag for anything, you break the numbered seal which then requires a full replacement bag at the ED.

SO... Before you can swap your med bag, you have to fully complete a PCR, print a copy, drive to the local base hospital, which is usually NOT where you've brought the patient, go to the pharmacy, (or find the night nursing supervisor if it's after hours) sign in your old drug bag, fill out a narc/med use form, waste any leftovers in front of the pharm (or RN if the pharmacy is closed), tape your now empty vial or carpo to the PCR and seal that in the OLD bag, get a new bag, break the pharmacy seal, count the contents, re-seal with a new numbered seal, sign a med bag form and then you're able to go run another call.

Biggest pain ever.

When I asked why we don't refill our bag from the Pyxis, they looked at me like I had two heads. "What? Give a paramedic access to the Pyxis? Never!!!"

Have I given fewer meds than I have in the past? Yep. You betcha.


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## DesertMedic66 (Oct 28, 2015)

We don't restock a single item from the hospital and for our narcotics we use an in house system so we don't have RNs witness our wasted drugs nor do we have to keep the vial. Our partner for the day EMT or Medic witnesses the drug waste.


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## Tigger (Oct 28, 2015)

DEmedic said:


> Well, I guess it depends on where you are. At the service I'm working at PRN, giving ANY medication is a huge pain in the balls. Any Med, not just narcs. Even zofran.
> 
> If you open a message bag for anything, you break the numbered seal which then requires a full replacement bag at the ED.
> 
> ...


God that sounds terrible.


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## ERDoc (Oct 28, 2015)

MonkeyArrow said:


> Aside from that, I feel like especially in an urban environment, and working in an ED where I can see the other side of the coin, I don't see the need for aggressive pain management with 10-15 minute transports. Likely by the time the med actually starts making a difference, you're pretty close to the hospital and giving things pre-hospitally messes up the ED "flow" if you will. For example, we do not give narcotics in the ED unless you are either getting admitted or have a ride home. If you are driving home, no candy for you. Most medics don't really think about that. Also, having the advantage of seeing a lot of our patient's EMR, you feel a lot more jaded when you see someone with 10/10 pain acute onset lower back pain, but they've been at the ED every month and have had 30 of hydrocodone filled a week ago.









Where do I even begin?  Why should anyone have to suffer any longer than they have to?  Paperwork is no excuse.  You are being paid to take care of people and that is what you do.  Paperwork is just part of the job.  Yeah, you may be at the hospital in 10-15 minutes but it is going to be at least another 30 minutes before they get any meds in the ER.  Do you want to suffer with a fractured hip for over 1 hour, when you could have been treated earlier?  That is just cruel. Giving things in the field DOES NOT mess up any flow in the ER.  There are plenty of people that get sent home that benefit from narcs (kidney stones, fractures, dislocations, DVTs, biliary colic, bad lacerations, pyelo, etc).  Why would you not treat these people?  Yes, driving home is a concern but that is not something EMS should be worrying about.  We all have our frequent fliers and we know who they are.  With experience, it becomes somewhat easier to identify who does and does not need narcotic pain meds.  Always remember that even the frequent fliers actually get sick sometimes.


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## NomadicMedic (Oct 28, 2015)

Tigger said:


> God that sounds terrible.



It, quite simply, blows.


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## MonkeyArrow (Oct 29, 2015)

On the med control issue here, you contact the hospital that you're transporting too and speak with an ED doc there and that's base control for you. 

And I'm obviously not advocating withholding pain meds from the obvious hip fracture/long bone fracture/whatever. But I said AGRESSIVE protocols and I still don't think you need to be medicating the questionable/grey area ones in urban environments. A crew once brought in a lady who jammed her finger in her car door with 50mcg of fentanyl on board. Sure, she may be in pain, but that's one I don't think I would have medicated.


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## TransportJockey (Oct 29, 2015)

MonkeyArrow said:


> On the med control issue here, you contact the hospital that you're transporting too and speak with an ED doc there and that's base control for you.
> 
> And I'm obviously not advocating withholding pain meds from the obvious hip fracture/long bone fracture/whatever. But I said AGRESSIVE protocols and I still don't think you need to be medicating the questionable/grey area ones in urban environments. A crew once brought in a lady who jammed her finger in her car door with 50mcg of fentanyl on board. Sure, she may be in pain, but that's one I don't think I would have medicated.


If she's in pain, stable,  and i have a minute you're damned right im going to medicate that finger.  And 50mcg of fent is about half of our normal starting dose.  Hell she sounds like a good candidate for intranasal fent


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## TransportJockey (Oct 29, 2015)

DEmedic said:


> Well, I guess it depends on where you are. At the service I'm working at PRN, giving ANY medication is a huge pain in the balls. Any Med, not just narcs. Even zofran.
> 
> If you open a message bag for anything, you break the numbered seal which then requires a full replacement bag at the ED.
> 
> ...


I would be out of service so much they might reconsider that protocol


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## cruiseforever (Oct 29, 2015)

Remi said:


> Us old school guys were trained that way.
> 
> Not that that's an excuse for poor care, but the attitude towards prehospital analgesia has changed dramatically in just the past 5-10 years.



I agree with Remi.  We used to call for orders when we wanted to give pain meds.  If we were lucky the pt. with the open tib/fib fx would get 5 mg of Morphine.  Changes were made 10-15 years ago, and now we can be very aggressive in treating pain, using Morphine, Fentanyl, Versed, and Ketamine.

But on the flip side of this.  There is a strong push by the hospitals in the area to reduce the use of pain medications with pts. that have chronic pain issues or minor trauma.  That has put pressure on us to be more selective in the pts. that will get pain meds.  Example would be:  Pt. has pain in his ankle after he tripped and fell.  If there is no visible trauma such as deformity, swelling, bruising and B/P and pulse are within normal limits.  He will not receive any pain meds.  He will get a cold packs, position of comfort and a smooth ride to the ER.

While it maybe true that there are older medics that are not very good at treating a pt.'s pain.  The same can be said about medics that are too loose in giving out the narcotics.  They tend to be newer medics.


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## chaz90 (Oct 29, 2015)

MonkeyArrow said:


> On the med control issue here, you contact the hospital that you're transporting too and speak with an ED doc there and that's base control for you.
> 
> And I'm obviously not advocating withholding pain meds from the obvious hip fracture/long bone fracture/whatever. But I said AGRESSIVE protocols and I still don't think you need to be medicating the questionable/grey area ones in urban environments. A crew once brought in a lady who jammed her finger in her car door with 50mcg of fentanyl on board. Sure, she may be in pain, but that's one I don't think I would have medicated.


I'm not really seeing why the urban environment has so much bearing. Transport involves movement, and movement hurts. Some conditions hurt anyway, and we can start to get the pain under control long before the process can start at the ED, even if it is 5 minutes away. 

After I get on scene with a patient with, say, kidney stones and severe flank pain, I can start an IV and administer meds in the first 5 minutes of patient contact as BLS prepares a stair chair and stretcher. If I didn't do that and left the patient hurting, extrication from the third floor back bedroom may take 10 minutes even if we're moving efficiently, loading into the ambulance another 2-3 minutes as we get everything reconnected and put away, 5 minute transport, 10 minutes waiting for a room/waiting for a nurse to transfer care, completing the registration process, having the nurse recognize the need for pain management and grabbing a doc/PA, having orders written, drawing from the PYXIS, and then finally administering them. This is assuming the ED isn't slammed with patient volume or high acuity too. 

Even conservatively with the ED functioning fairly well, the time difference between me providing pain management on scene (as I have one patient to deal with and meds readily accessible) vs. transporting to an urban hospital and waiting can easily reach 30-45 minutes. I don't think that's an exaggeration in the slightest from EMS patient contact to hospital ED treatment even from a short distance away.


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## reaper (Oct 29, 2015)

MonkeyArrow said:


> On the med control issue here, you contact the hospital that you're transporting too and speak with an ED doc there and that's base control for you.
> 
> And I'm obviously not advocating withholding pain meds from the obvious hip fracture/long bone fracture/whatever. But I said AGRESSIVE protocols and I still don't think you need to be medicating the questionable/grey area ones in urban environments. A crew once brought in a lady who jammed her finger in her car door with 50mcg of fentanyl on board. Sure, she may be in pain, but that's one I don't think I would have medicated.


Well, try this. Let me slam you finger in a car door and then tell me if you want pain meds.

Most EDs do not care what pts get pain meds. That is up to the medic on scene. It is up to you to assess your pt and treat accordingly. 

Some medics act like they are using pain meds from their personal stash. Treat your dam pts!


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## Bullets (Oct 29, 2015)

H33 said:


> I don't disagree.. but true it is.. south alabama 12 trucks 5 counties. 10 of which ALS


You guys dont even have like ketamine for RSI or something? Fentanyl lozenges? 



MonkeyArrow said:


> If you contact a hospital for base orders, don't you have to transport to that hospital?
> 
> Aside from that, I feel like especially in an urban environment, and working in an ED where I can see the other side of the coin, I don't see the need for aggressive pain management with 10-15 minute transports. Likely by the time the med actually starts making a difference, you're pretty close to the hospital and giving things pre-hospitally messes up the ED "flow" if you will. For example, we do not give narcotics in the ED unless you are either getting admitted or have a ride home. If you are driving home, no candy for you. Most medics don't really think about that. Also, having the advantage of seeing a lot of our patient's EMR, you feel a lot more jaded when you see someone with 10/10 pain acute onset lower back pain, but they've been at the ED every month and have had 30 of hydrocodone filled a week ago.


You guys call different hospitals for orders? We just call one hospital no matter where we are transporting too. Our OMLC is an hour north of us. 

I dont think about some of these things because literally, i dont care. I dont care if they dont have a ride, if they are in pain NOW, then they get treatment NOW. When they are with me it is the only time the Provider/patient ratio is in their favor. I can provide pain relief now so when they get to the ER and wait 2 hours for a room and maybe 30 minutes or more between seeing one nurse they have some relief, because after i transfer care its going down hill. 

As far as drug seekers, if the worst thing they can put on my tombstone is "Bullets trusted the patient and gave analgesia to too many people" ill rest peacefully. Im not the cops, its not my job to find out who is looking for drugs. If you tell me youre in pain and my assessment agrees with your chief complaint, then i will treat accordingly. What if that drug seeker is really in pain this time? Youre going to withhold treatment because of past experiances? Thats not my concern. 



DEmedic said:


> SO... Before you can swap your med bag, you have to fully complete a PCR, print a copy, drive to the local base hospital, which is usually NOT where you've brought the patient, go to the pharmacy, (or find the night nursing supervisor if it's after hours) sign in your old drug bag, fill out a narc/med use form, waste any leftovers in front of the pharm (or RN if the pharmacy is closed), tape your now empty vial or carpo to the PCR and seal that in the OLD bag, get a new bag, break the pharmacy seal, count the contents, re-seal with a new numbered seal, sign a med bag form and then you're able to go run another call.


Seems like a great way to avoid doing jobs when your busy or lazy...OOS restocking


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## NomadicMedic (Oct 29, 2015)

Bullets said:


> Seems like a great way to avoid doing jobs when your busy or lazy...OOS restocking



Nothing great about it. It's seriously the most convoluted system I've ever seen.


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## DesertMedic66 (Oct 29, 2015)

Bullets said:


> You guys dont even have like ketamine for RSI or something? Fentanyl lozenges?
> 
> 
> You guys call different hospitals for orders? We just call one hospital no matter where we are transporting too. Our OMLC is an hour north of us.
> ...


We have Base Hospitals that we have to contact for any orders we want and for some patients. Our other hospitals are just Paramedic Receiving Centers which means we can transport to them and we call them just to give them a heads up but we are not able to get orders from the hospital.


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## RocketMedic (Oct 31, 2015)

I feel like Remi's viewpoint is exactly why people don't get adequate analgesia from most paramedics. Sure, there's plenty of situations where analgesia is unnecessary, inappropriate with opiates or can be accomplished with alternative measures, but the Remis and cruiseforevers and Monkey arrows of the world don't all differentiate between those cases and cases where opiates are indicated and quite helpful.


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## Carlos Danger (Oct 31, 2015)

RocketMedic said:


> I feel like Remi's viewpoint is exactly why people don't get adequate analgesia from most paramedics. Sure, there's plenty of situations where analgesia is unnecessary, inappropriate with opiates or can be accomplished with alternative measures, but the Remis and cruiseforevers and Monkey arrows of the world don't all differentiate between those cases and cases where opiates are indicated and quite helpful.



Yep. Folks like me are definitely the reason people don't get adequate analgesia from "most paramedics".

What do I know, after all?

Edit: and the term is "opioid", not "opiate". Please at least learn the basic terminology before you try lecturing me about this stuff.


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## teedubbyaw (Oct 31, 2015)

Remi said:


> What do I know, after all?


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## epipusher (Oct 31, 2015)

Remi said:


> Yep. Folks like me are definitely the reason people don't get adequate analgesia from "most paramedics".
> 
> What do I know, after all?
> 
> Edit: and the term is "opioid", not "opiate". Please at least learn the basic terminology before you try lecturing me about this stuff.


Yet again I support Rocket in another Remi v. Rocket discussion. This last post speaks volumes.


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## RocketMedic (Oct 31, 2015)

medic5678 said:


> It had better be real and severe before I'm happy giving anything.   Absent any obvious injury.. the more drama, the less real I think it is.  They start saying they're allergic to everything except what they want?  My Bull Sh*t detector goes off!



And what, pray tell, is your definition of "real and severe?"


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## 46Young (Oct 31, 2015)

We have Fent 1mcg/kg, max single dose of 100mcg, max total of 200mcg, and we can call for more. 1/2 single dose, but same cumulative dose for pts 65 y/o or older. We carry 400mcg on our rigs. We're now able to incorporate Ketamine into pain management as well. Burn pts. and pts already on opiods may need more than 200mcg, but otherwise what we have does a decent job most of the time.

PPW and OOS time for restock is not a concern. It takes me 10-15 minutes tops to do the waste, get signatures, and get a new narc pouch from the pharmacy.

As far as seekers/frequent fliers, a little psychology and observation is needed. I try to get them distracted with some in-depth conversation, and see if they forget to act like they're in pain for a moment or two. When you have more than two minutes on the job, you'll see who's really suffering, and who's putting on a show to get some free drugs. I've had plenty of psych patients be chill during txp, and then become profoundly combative as we pull into the ED, knowing that they'll be chemically restrained with goodies like Versed, Ketamine, and Haldol from the ED staff.

Having said that, if a patient appears to be in withdrawal, it is barbaric to let them suffer when you could give them some Fent, which is fairly short acting and isn't very strong, which may curb their withdrawal Sx. If the patient is just putting on a show, where they present normal when you engage them in conversation, then act ill in the interim, the simple solution is to start the line two minutes away from the hospital so you're taping the line down as your partner is opening the doors, or document their pain scale according to FACES instead of the numeric scale, to keep QA/QI off of your back.

I may or may not have given a placebo NS flush once or twice back in the day, with an "observable reduction in perceived pain." lol


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## teedubbyaw (Oct 31, 2015)

Max single dose of 100? Pfft. My last tib/fib guy got 200 off the bat, finishing at 300. Would have given him another 100 if time permitted. So many protocols are uptight with fentanyl.


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## RocketMedic (Oct 31, 2015)

If I'm not going to give meds, I simply don't bring it up.

For what it's worth, the placebo effect is not ethical and I do not think it is a good or supportable practice.


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## Akulahawk (Nov 1, 2015)

I'm a big fan of giving pain control. Unfortunately, where I work, we see a LOT of drug seeking behavior. Of course we also see a LOT of kidney stones. There's a very good drug that we use a LOT... Toradol. Yes, it's a NSAID and there are reasons NOT to give it. However, I've seen patients get more relief out of some Toradol than with morphone or dilaudid. Those patients that are seeking usually get really angry at the Toradol offer... Darned near every patient that has gotten Toradol (that can get it) usually end up back in the ED asking for it. They get nothing out of it except relief. 

When I was working in the field, I would have really liked to have a non-narcotic IV option... and Normazaline isn't a good substitute or good medicine.


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## cruiseforever (Nov 1, 2015)

RocketMedic said:


> I feel like Remi's viewpoint is exactly why people don't get adequate analgesia from most paramedics. Sure, there's plenty of situations where analgesia is unnecessary, inappropriate with opiates or can be accomplished with alternative measures, but the Remis and cruiseforevers and Monkey arrows of the world don't all differentiate between those cases and cases where opiates are indicated and quite helpful.



Not sure where you got the idea that I am unable to differentiate between pts. that need pain control and those that do not?   I feel I do a very good job of treating my pt's. pain and I would think most of my pts. would agree.


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## triemal04 (Nov 1, 2015)

cruiseforever said:


> Not sure where you got the idea that I am unable to differentiate between pts. that need pain control and those that do not?   I feel I do a very good job of treating my pt's. pain and I would think most of my pts. would agree.


Don't.  Please, please don't start.   The last 3 months have been very nice, so before you get involved in what you think will be an open debate, maybe check out the post history.   It's enlightening.


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## RocketMedic (Nov 1, 2015)

cruiseforever said:


> The same can be said about medics that are too loose in giving out the narcotics. They tend to be newer medics.



And what is "too loose"?


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## NomadicMedic (Nov 1, 2015)

RocketMedic said:


> And what is "too loose"?



You know it when you see it. 

A woman on her cell phone, complanning of 10/10 foot pain, does not need 100 of fent. 

A woman with an angulated fx of her tib/fib, moaning in pain, does. 

I know several medics who would medicate neither and another medic who would medicate both. 

Too tight and too loose. 

Determination of actual pain is difficult, but experience and situational awareness will usually help in guiding your pain management practice. Unless, of course, you have no skill in reading nuance...


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## cruiseforever (Nov 1, 2015)

DEmedic said:


> You know it when you see it.
> 
> A woman on her cell phone, complanning of 10/10 foot pain, does not need 100 of fent.
> 
> ...



That sums it up nicely.


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## RocketMedic (Nov 1, 2015)

cruiseforever said:


> That sums it up nicely.



Yet your original post comes across as that of an angry old man, yelling at clouds. "Their vitals need to reflect pain"- type logic.


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## Chewy20 (Nov 1, 2015)

teedubbyaw said:


> Max single dose of 100? Pfft. My last tib/fib guy got 200 off the bat, finishing at 300. Would have given him another 100 if time permitted. So many protocols are uptight with fentanyl.



Post your protocols.


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## EpiEMS (Nov 1, 2015)

DEmedic said:


> You know it when you see it.
> 
> A woman on her cell phone, complanning of 10/10 foot pain, does not need 100 of fent.
> 
> ...



I would tend to say it's hard to design a system (especially a large one) where "you know it when you see it" leads to the same outcomes across many providers. That's where good protocols or some sort of overriding assumption come(s) into play. Not to say that a qualitative reasonableness standard isn't good, just that it's insufficient on its own. 

(I'm not entirely qualified to speak on this, of course, being that I'm limited to positioning, splinting, and hot/cold packs, which are often wholly inadequate...)


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## SeeNoMore (Nov 1, 2015)

We operate under fairly liberal protocols are are expected to treat pain , and document a management strategy that includes the patient's wishes if they are able to make their needs known. For example, an individual might get an initial dose of fentanyl and then determine that their pain is at an acceptable level vs additional meds.  I err on the side of providing at least some pain management to any patient who complains of pain, and would like pain meds. If a complaint of pain seems exaggerated  I might follow up an initial dose with the statement "I've given you something for the pain, we will be at the hospital soon and they can give you more." If it's a long transport I will still follow this up with another check in / discussion about their pain and usually more meds. I don't view it as my place to determine whether someone is faking ,  but of course I don't necessarily empty the drug box on someone complaining of 10/10 pain with no apparent distress, no abnormal v/s, etc.


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## Akulahawk (Nov 2, 2015)

DEmedic said:


> You know it when you see it.
> 
> *A woman on her cell phone, complanning of 10/10 foot pain, does not need 100 of fent. *
> 
> ...


For those, I'd say to get be sure to ask in-depth about the PMH. Sometimes you find something that just tells you the patient isn't drug seeking.


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## cruiseforever (Nov 2, 2015)

RocketMedic said:


> Yet your original post comes across as that of an angry old man, yelling at clouds. "Their vitals need to reflect pain"- type logic.


 
Angry old man, not yet.  Still in the grumpy old man stage.

 The post you refer to is an example of what our medical director wants done if the injury does not appear to equal the amount of pain the pt. is complaining of.  He feels if the person's pulse is not elavated, does not c/o nausea, or is diaphoretic, to be cautious in treating their pain.  But to take in account the pt. maybe on Beta blockers and other meds. that may affect the pt.'s vitals.

The medical community in our area has decided to be more selective on ways to treat pain, instead of just pumping them full of narcotics.  That in turn has caused us to be more selctive on how we treat our pts..  Since we have made changes in treating pain, we have recieved very few complaints from the pts. about not treating their pain.  And the number of complaints from the ERs about over medicating a pt. has decreased.


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## triemal04 (Nov 2, 2015)

cruiseforever said:


> The medical community in our area has decided to be more selective on ways to treat pain, instead of just pumping them full of narcotics.  That in turn has caused us to be more selctive on how we treat our pts..  Since we have made changes in treating pain, we have recieved very few complaints from the pts. about not treating their pain.  And the number of complaints from the ERs about over medicating a pt. has decreased.


Like the medical community at large really.  Except of course for EMS that is (since EMS is generally 5-10 years behind the times that really isn't surprising).  Apparently blatantly handing out gobs of narcotics to anyone who uses the word "pain" is a bad idea.  Who knew?


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## NomadicMedic (Nov 2, 2015)

Akulahawk said:


> For those, I'd say to get be sure to ask in-depth about the PMH. Sometimes you find something that just tells you the patient isn't drug seeking.



 Right, but read the  REST of what I posted... 





> Determination of actual pain is difficult, but experience and situational awareness will usually help in guiding your pain management practice. Unless, of course, you have no skill in reading nuance...


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## CALEMT (Nov 2, 2015)

DEmedic said:


> A woman on her cell phone, complanning of 10/10 foot pain, does not need 100 of fent.


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## UpstateMedic4459 (Mar 26, 2016)

Tigger said:


> There are several Albany area services that do the same. It's not a required medication, so they don't carry it and therefore avoid "regulatory" issues.


I've noticed that some of the ALS Fire Departments Up here only the Rescue Rig or the Chief are the only ones who carry them


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## Inspir (Apr 18, 2016)

Morphine is still our go to for pain management. We have fentanyl but our protocol reserves it for poly-trauma or morphine allergy patients.

We also carry entenox which you can administer concurrently with morphine or fentanyl which works great.


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## usalsfyre (Apr 19, 2016)

triemal04 said:


> Like the medical community at large really.  Except of course for EMS that is (since EMS is generally 5-10 years behind the times that really isn't surprising).  Apparently blatantly handing out gobs of narcotics to anyone who uses the word "pain" is a bad idea.  Who knew?


Except that EMS and EM treatment of acute pain never has been, and still isn't, what's caused the opioid issue in the US. Core measures forcing long-term narcotic scripts followed by the DEA yanking the rug out from under opiate-dependent patients has led to the current heroin crisis.


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## Inspir (Apr 19, 2016)

I look at it from the perspective if I was the patient. If I was in any pain I don't want to feel a thing. And having the unfortunate event of breaking a femur I am glad I had an ALS crew who were very liberal with pain management.


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## Carlos Danger (Apr 20, 2016)

Inspir said:


> I look at it from the perspective if I was the patient. *If I was in any pain I don't want to feel a thing*. And having the unfortunate event of breaking a femur I am glad I had an ALS crew who were very liberal with pain management.



I'm not sure you really meant "not feel _a thing_", so I'm not picking on you at all, just using this statement as an example of something that we hear all the time, and is actually quite problematic. Many people DO mean they don't want to feel a thing.

The expectation that pain should never exist at all is unrealistic, unreasonable, and ultimately even counterproductive to the overarching goals of our healthcare system. Unfortunately, this expectation has been heavily reinforced since the 1990's, to the point that a patient's satisfaction with their care (which is highly subjective and variable and dependent on many individual factors, of course) is dependent largely if not mostly on their perception of how well their pain was managed. Give patients enough of "that one that starts with a D" and they are satisfied with their care. Don't give them enough and they aren't satisfied. Little else matters to many people. Except of course how long they have to wait to get "that one that starts with a D".

For a couple decades now patients have been told that they are _entitled _to be pain free, and if that requires a large supply of potent opioids, then they have a _right_ to those drugs. Accordingly, doctors and facilities have been punished for trying to take a more moderate and reasonable approach to analgesia. We are all familiar with where this has led us. It has in at least some cases shifted the focus from areas of care that are more important, it has exposed a huge part of the population to doses of opioids that were not necessary or safe, and it has seriously skewed many people's perceptions of what constitutes quality medical care. Now in an effort to combat the problems caused by this approach, the pendulum is beginning to swing back in the opposite direction, and that won't be a good thing either.

The reality is that pain is a normal physiologic response (and experience) to injury or illness. It is just one of the many unpleasant facts of life that everyone will go through. If you have surgery or suffer a traumatic injury, it is going to hurt. The only way to make it not hurt at all is to expose you to large doses of powerful chemicals that can have untoward effects on your physiology and your psychology. Yes, there are problems with not managing pain. But no one is suggesting that we not manage pain. Part of managing pain properly is having a realistic expectation of it.

What does this have to do with EMS? Am I saying we shouldn't treat pain? It really doesn't have a _whole_ lot to do with EMS, because for the most part we aren't talking about problems arising from the very early phases of managing an acute injury, in which case we should of course treat severe pain. But many folks in EMS now weren't around in the days before everyone was on opioids, and seem to have the same misperceptions about pain and what is reasonable for patients to experience. All the comments you see on this and other EMS forums to the effect of "there's no reason patients should be in pain at all" reflect a misunderstanding of effective pain management and in at least a small way, contributes to the larger problem.


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## SpecialK (Apr 20, 2016)

Treatment of acute pain is one of the best things ambulance personnel can do.

Our patients are fortunate to have a great many options available to them depending on how severe their pain is:

Paracetamol
Ibuprofen
Tramadol
Entonox
Methoxyflurane
Morphine
Fentanyl
Morphine or fentanyl plus midazolam
Ketamine
Lignocaine 1% ring blocks

Many patients only require inhaled pain relief plus the oral triple combo (paracetamol, ibuprofen and tramadol) once they are in a position to swallow the tablets which takes care of the acute pain and means they won't have an immediate need for pain relief when arriving in hospital.  If the patient has a minor condition and does not need immediate referral to somebody else then they can be left with a blister of paracetamol and ibuprofen for later on as well as being given a stat dose.

Morphine is great for most acute pain but big doses are not very nice on some folk so fentanyl is good for these patients, and is also good when trying to analgise somebody who is a little bit on the poor side.  Since we got ketamine about 10 years ago I just couldn't live without it anymore, most wonderful stuff I have ever seen.  Lignocaine ring blocks 1% are pretty nifty, I haven't used them but the thrust of the idea of providing local instead of systemic analgesia is a good one.  Who knows, it might be extended at some point to hands or wrists or ankles.


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## TransportJockey (Apr 20, 2016)

I have done digital blocks. Makes  a world of difference for severe hand injuries.


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## NUEMT (Apr 20, 2016)

Critmedic has 2 inaugural podcasts on the war on pain.   A lot of good comments here backed up by sound logic and experience.  Jeep has the autonomy to decide what he will do unlike many posters here but to that I agree with most of what he has said.  For me the issue of pain management in the pre-hospital setting goes beyond, or rather, rises above (like a drone with a camera not in a "I'm better" way) the general discussion of what meds or what protocols.  It also I think rises above those who would view themselves as gatekeepers to pain management.  The fact is, without deep understanding of pain types and presentations, you are often just guessing.  Usually the exceptions to the rule are what we remember. We have all seen and heard comments surrounding pain that would make us cringe.  So what do we do? 

Participating in research and advocating for our profession in our respective systems is a good place.  Conversations about this issue outside of the 10, 50, or 100 pts you have seen in your area and your system and taking a real look at attitudes and methods outside of your box.  This is key.  Add context to your practice and you will find either a sense of satisfaction or a hunger to improve your system.  Clare's perspective is always nice to hear for instance.  We are not the only place in the world doing EMS, and we certainly aren't the best.  Somethings we do are great, and some things we do are about as useful as MAST pants.  

I will be doing further research into the use of Ketamine to be able to present to my medical director in the near future.  Weingart, Minh Le Cong, and others have recently been advocating for its use and having reviewed the literature, I am thinking along the same lines.  

My hope is that you all will do the same and gain some perspective on where your thinking sits on the wave of changing thoughts on medicine. You might be surprised.


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