# Pain management



## Alas (Nov 2, 2013)

Hypothetical:

Drive by, pt flags you down, 30-70 yrold states 10/10 sudden onset leg pain, throbbing, constant, non radiating non traumatic. Appears in no distress. Vitals stable, hx irrelevent. Wants to go to hospital, en route says he wants morphine. Same person flags you down everyday for different complain.

What are hypothetical valid scenarios to reasons not to give morphine?

How about pain of unknown etiology? 
What if pt was inconsitent with story, therefore slightly confused, a contradiction for morphine?

Any other possible scenarios or reasons?


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## abckidsmom (Nov 2, 2013)

What are his vitals? How do they compare to his normal hr/BP?

What does your gut say?

What is the possible etiology of the pain?

How long is the transport time?

Typically, I need to observe a little bit of distress before I decide to I've narcotics. But I look closely- lines around mouth, sweat on lip/brow, hand position, posture. If they look like they're in pain I will treat them, but all the physiologic signs need to point that way.


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## DrankTheKoolaid (Nov 2, 2013)

Also remember that not all pain will cause increases in VS so this isn't as accurate assessment as most think. People with (true) chronic pain can actually have there VS lowered (paradoxical) from acute exacerbation of chronic pain.


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## Anjel (Nov 2, 2013)

Depending on the big picture. Could he walk on the leg? Any abnormalities noted? Anything that abc listed? Most likely I would not treat based on what you listed and I would most likely call for a BLS ambulance to transport. Dispatch gets mad when 911 cars go out Of service if they don't have to. 

Especially if we transport this person everyday. If this was my first time seeing this person, who am I to judge. 

Ie heard this following statement and I believe it to be true...

I would rather give pain meds to 100 seekers than withhold it from 1 person that is truly in pain.


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## jwk (Nov 2, 2013)

Your hypothetical has too many inconsistencies, so, based solely on your hypothetical, no narcs.

Pain 10/10 but no distress and hx irrelevant, and a different complaint every day on top of that?  Nah, I don't think so.

And sorry, I disagree totally with the concept of treating 100 improperly so that you don't miss one that really needs help.  Those kinds of blanket statements are a poor excuse for providing treatment at any level.


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## epipusher (Nov 2, 2013)

Regardless of whether it's a first time transport or the 100th time you are still passing judgement.


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## Anjel (Nov 2, 2013)

jwk said:


> Your hypothetical has too many inconsistencies, so, based solely on your hypothetical, no narcs.
> 
> Pain 10/10 but no distress and hx irrelevant, and a different complaint every day on top of that?  Nah, I don't think so.
> 
> And sorry, I disagree totally with the concept of treating 100 improperly so that you don't miss one that really needs help.  Those kinds of blanket statements are a poor excuse for providing treatment at any level.



Not necessarily. I mean yes it is a blanket statement. But if someone appears to be in distress, who are you to say they are faking. You have to do a proper assessment and based on clinical findings base your treatment. Not on your opinion of what kind of person it is, and whether or not you think they deserve pain meds. People handle and react to pain differently.


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## truetiger (Nov 2, 2013)

Do your findings match the subjective complaint? If not, no pain meds. I could honestly care less what they rate their pain at if the exam findings are inconsistent with the complaint. You have to consider the big picture, especially if the patient has a hx of frequently reporting vague complaints and asking for pain meds. Are we passing judgement? Absolutely! In fact, our protocols are written that way. 

"The purpose of this treatment Protocol is to give xxx Paramedics the ability to properly assess and treat patients in pain without having to consult Medical Control prior to administration."

"Caution – Paramedic judgment must always consider safety and efficacy in administration of analgesics."


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## Alas (Nov 2, 2013)

Let me reword the question sorry.

Let's say as a FACT this was a drug seeker. What are some reasons not to give a controlled narcotic to this patient?


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## DesertMedic66 (Nov 2, 2013)

Alas said:


> Let me reword the question sorry.
> 
> Let's say as a FACT this was a drug seeker. What are some reasons not to give a controlled narcotic to this patient?



When it's not indicated.


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## epipusher (Nov 2, 2013)

It is unfortunate that some of you are colleagues.


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## Akulahawk (Nov 2, 2013)

Another thing to remember (no idea if it's relevant in this case) is that some people who deal with chronic pain may complain of (and actually have) 10/10 pain somewhere but are absolutely used to being in pain so they don't show any outward signs of such intense pain. They might "live with" and tolerate 8/10 pain, but bump it up a couple and it's not tolerable anymore but they'll still not have any major outwardly noticeable signs of pain.


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## jwk (Nov 2, 2013)

epipusher said:


> Regardless of whether it's a first time transport or the 100th time you are still passing judgement.



A better term would be "assessing your patient".  As others have pointed out, pain is more than just a rating on a pain scale.  I have patients barely awake after anesthesia, between snores and their SaO2 at 88, telling me their pain scale is 10/10.  Do I believe them?  No.  Do I automatically give them more narcs?  Of course not.  I'm not judging them - my assessment tells me that at this point in time, giving narcotics is not in their best interest.  That's not cruel or mean - it's reasonable care.


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## Rialaigh (Nov 3, 2013)

Anjel said:


> Not necessarily. I mean yes it is a blanket statement. But if someone appears to be in distress, *who are you to say they are faking.* You have to do a proper assessment and based on clinical findings base your treatment.* Not on your opinion of what kind of person it is*, and whether or not you think they deserve pain meds. People handle and react to pain differently.



You are to say, because you are a medical professional that is tasked with deciding whether or not they are faking. Social history, past history of  drug or substance abuse, past history of non emergent and vauge complains, and past history of pain scale during those complains is going to be very very accurate about whether this person needs narcotics, before actually looking at the current complaint or vitals or physical assessment. 

Your opinion of what kind of person it is (if you are good at assessing people) will be very accurate in telling you whether the complaint is serious at all in many many cases.


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## Ewok Jerky (Nov 3, 2013)

Just because they are a drug seeker or have a drug history doesn't mean they are immune to pain/are in pain today.


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## DrankTheKoolaid (Nov 3, 2013)

This is the reason we should be given choices such as toradol stadol and Nubain


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## Brandon O (Nov 3, 2013)

There should be a policy in place that specifically addresses the role and responsibilities of paramedics in limiting drug-seeking behavior. The responsibility of providing pain management is clear, so if the countervailing motivation isn't clear then you have very little to draw upon except personal attitudes.


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## terrible one (Nov 3, 2013)

I have no problem giving out pain meds wether it's to a seeker or not, however, they still warrent an assessment. I wouldn't just blindly hand over narcs because someone asks for it.


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## Anjel (Nov 3, 2013)

terrible one said:


> I have no problem giving out pain meds wether it's to a seeker or not, however, they still warrent an assessment. I wouldn't just blindly hand over narcs because someone asks for it.



This Is what I was trying to get across. I didn't do a very good job. Lol

Just because someone has a history, doesn't mean that you don't assess them TODAY and see what's going and and what's different TODAY. Don't let you're opinion of what kind of person they are cloud your judgement.


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## truetiger (Nov 3, 2013)

All I'm advocating is that you do a thorough assessment. A verbal pain scale is just one piece of that puzzle. Patient request is not an indication for medication.


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## PFDEMT (Nov 3, 2013)

This is silly.. 
all our reading into the situation way to much..
we do NOT have to give px meds. we are required to treat based on WHAT we see..  I say pt goes bls then the docs decided to give px meds. 

If your taking him to the hospital every day then he should have a full house of px meds. Odds our he needs a ride to down and needs a fix..


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## epipusher (Nov 3, 2013)

PFDEMT said:


> This is silly..
> all our reading into the situation way to much..
> we do NOT have to give px meds. we are required to treat based on WHAT we see..  I say pt goes bls then the docs decided to give px meds.
> 
> If your taking him to the hospital every day then he should have a full house of px meds. Odds our he needs a ride to down and needs a fix..


I ferl sorry for ALL of your patients.


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## PFDEMT (Nov 3, 2013)

Havnt had a complaint yet.   

They post states a guy 30-70 y/o 

1-- if a guy that is 30 looks 70 odds are drugs aged him 
2---a guy is flagging you down not calling 911 day after day.. 

3--- its a different complaint everytime.. 

I just know what the post gave me and screams
frequent flyer for drugs and ride... 
if its truley an emergency he wouldnt be out side flagging down ems.


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## PFDEMT (Nov 3, 2013)

epipusher said:


> I ferl sorry for ALL of your patients.



Havnt had a complaint yet.:censored:

They post states a guy 30-70 y/o:censored:

1-- if a guy that is 30 looks 70 odds are drugs aged him:censored:

2---a guy is flagging you down not calling 911 day after day..:censored:

3--- its a different complaint everytime..:censored:I just know what the post gave me and screamsfrequent flyer for drugs and ride...:censored:if its truley an emergency he wouldnt be out side flagging down ems


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## Christopher (Nov 3, 2013)

It is seriously pretty simple:

"Ma'am/sir, you've told me your pain is X out of 10. Would you like me to give you anything for the pain? Are you allergic to <insert medication appropriate to clinically correlated pain assessment and scale>?"

Was that so hard?

Then in <insert rebolus interval here>:

"Ma'am/sir, now that we've given it some time, what is your pain level now?....Ok, would you like anything more for the pain?"

Done and done! It is almost like we're treating patients 'n stuff.


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## triemal04 (Nov 3, 2013)

epipusher said:


> I ferl sorry for ALL of your patients.


And I feel sorry for all of your patients since you apparently aren't capable of assessing a patient and then creating a treatement plan based on your findings.

If all you do, or are capable of doing is blindly giving medications or performing procedures because someone tell's you something and ignoring the rest of your clinical findings and whatever medical education and knowledge you have then you should never be in the position to independently practice medicine.

I don't know why people are so fanatical about this, other than a lack of education.  It's very simple, and no different than determining the correct treatement for a complaint of shortness of breath.  You assess your patient and determine if a treatement is needed, and if so, what the appropriate treatement is.  You do not blindly give out ANY medication without assessing the patient first.

End of story.


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## PFDEMT (Nov 3, 2013)

triemal04 said:


> and i feel sorry for all of your patients since you apparently aren't capable of assessing a patient and then creating a treatement plan based on your findings.
> 
> If all you do, or are capable of doing is blindly giving medications or performing procedures because someone tell's you something and ignoring the rest of your clinical findings and whatever medical education and knowledge you have then you should never be in the position to independently practice medicine.
> 
> ...






booooooommm!!!!


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## Carlos Danger (Nov 3, 2013)

DrankTheKoolaid said:


> This is the reason we should be given choices such as toradol stadol and Nubain



Stadol and Nubain are both opioids, too.

And they can be dangerous to give to opioid addicts.


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## epipusher (Nov 3, 2013)

PFDEMT said:


> booooooommm!!!!



My assumptions about your attitudes towards patients on and off this forum are probably not far off.


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## usalsfyre (Nov 3, 2013)

triemal04 said:


> And I feel sorry for all of your patients since you apparently aren't capable of assessing a patient and then creating a treatement plan based on your findings.
> 
> If all you do, or are capable of doing is blindly giving medications or performing procedures because someone tell's you something and ignoring the rest of your clinical findings and whatever medical education and knowledge you have then you should never be in the position to independently practice medicine.
> 
> ...



Why do I feel so strongly about this? Probably because I've seen "paramedics" (using the term extremely loosely) withhold pain meds from legitimate pathology far more than I've seen them make reasoned assessments, or give it inappropriately, especially if the patient in question doesn't meet the providers description of worthy of their care. EMS providers tend to be a judgmental bunch, and assessments and treatments often seem tailored to that provider's personal biases. Further, few paramedics actually delve into chronic pain, ect, and when they do it's an excuse to WITHHOLD meds rather than administer.

In short, you're right, many paramedics are incapable of using assessments to for a clear clinical picture and treatment plan, but in exactly the opposite way you think.


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## NomadicMedic (Nov 3, 2013)

Okay folks. Everyone take a deep breath or this thread gets my full, undivided attention.


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## PFDEMT (Nov 3, 2013)

epipusher said:


> My assumptions about your attitudes towards patients on and off this forum are probably not far off.



You must be one of those medics that think you can save the world..


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## triemal04 (Nov 3, 2013)

usalsfyre said:


> Why do I feel so strongly about this? Probably because I've seen "paramedics" (using the term extremely loosely) withhold pain meds from legitimate pathology far more than I've seen them make reasoned assessments, or give it inappropriately, especially if the patient in question doesn't meet the providers description of worthy of their care. EMS providers tend to be a judgmental bunch, and assessments and treatments often seem tailored to that provider's personal biases. Further, few paramedics actually delve into chronic pain, ect, and when they do it's an excuse to WITHHOLD meds rather than administer.
> 
> In short, you're right, many paramedics are incapable of using assessments to for a clear clinical picture and treatment plan, but in exactly the opposite way you think.


Then you work with far to many incompetant paramedics, and instead of insisting on a change to proper treatement you want that incompetance to be perpetuated and even extended to others who might be capable of appropriate decision making.  You want people to think that it is appropriate and right to treat patients without first knowing what treatement, if any, is actually needed.  In the many, many threads about this the common refrain is always "if the patient says they are in pain then I give them narcotics."  No mention of actually assessing their patient to determine what is, or isn't needed.  No mention of taking in the overall clinical context.  This is so far from proper care it is unbelievable, and to see people advocate this and think that it is in any way, shape or form appropriate is disgusting.  

Your job is to assess, and appropriately treat your patient.  It does not matter what their complaint is, be it shortness of breath, a cough, pain, or something else.  If you, or anyone else thinks that it is appropriate to blatantly give out any type of medication or treatement without first determining if it is needed then you belong in a different field.

***for the sake of keeping the thread open it should be noted that the "you" I'm referring to is an ambiguous one.***


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## Brandon O (Nov 3, 2013)

triemal04 said:


> Your job is to assess, and appropriately treat your patient.  It does not matter what their complaint is, be it shortness of breath, a cough, pain, or something else.  If you, or anyone else thinks that it is appropriate to blatantly give out any type of medication or treatement without first determining if it is needed then you belong in a different field.



This is undoubtedly true. What sort of assessment findings do you have in mind to inform this decision?


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## Ewok Jerky (Nov 3, 2013)

The International Association For the Study if Pain defines "pain" as:

Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.


Pain is an experience.  Its not something easily quantified objectively.  If your Pt tells you they are in pain, then we must assume that they are, in fact, in pain.


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## triemal04 (Nov 3, 2013)

Ok.  Let's look at a couple of things for acute issues.

Looking at physical signs is a start, but should NOT be the single deciding factor.  While severe pain will usually activate the bodies stress responce to some degree (elevated heartrate and BP) it may not happen all the time, or be that pronounced.  And potentially you may see a drop in the pulse if the patient is bearing down (transiently or not), which would also be worth noting.  Are they sweating?  Like everything here, it may or may not be present and this shouldn't be the deciding factor.

How is the patient holding themselves?  Does it fit with the reported location of pain and the cause (if there is one)?  Someone with a musculoskeletal injury will generally not be moving the affected part or making sudden movements with their body.  Example; severe back pain is generally when you will see someone laying very, very still and limiting any movement of any body part.  Rib injuries are similar; though not directly connected to the affected area, almost any movement hurts.  Curling up with some writhing with a vague complaint of abdomenal pain is different than doing the same while complaining of lower back pain.

Does your physical exam fit with the location and cause?  Lightly brushing your hand across a flat, non-distended abdomen shouldn't elicit a responce; actual palpation may.  For the abdomen, is the patient consistently gaurding?  If so does gentle palpation cause a reaction, or deeper?  Is your exam consistent?  If you come back to the same area with the same technique, is the responce the same?  If this was a traumatic injury or there any outward signs of injury?  Are they distractable during your physical; does firmly palpating a non-injured/painful area while gently palpating the reported part cause a responce?  

Does the history fit with the complaint?  If this was an acute traumatic injury, is the reported event consistent with the reported injury?  Has there been a change in the pain?  

Is the patient's story constant?  Does varying the format of your questions bring up a different responce?  Do their responces change if you ask several questions that are unrelated to the current issue before continueing with the history?

Are they distractable during the history?  Can you change the topic to something other than their complaint of pain and remain on it?  Does their demeanor change during this? 

That should be enough to get you started.  Obviously the examples given aren't meant to be a comprehensive list (I wish I didn't actually have to say that) but are just a few examples of the different things you should be looking at.

This is of course leaving out the "classic" signs of drug-seeking behavior, which, like the above, shouldn't be looked at by themselves but taken in as a whole.

Obviously all these things can be faked with effort, and in some patient's you won't be able to know for certain; pain is unfortunately a very subjective finding without outward signs that are "always" there.  At that point it is appropriate to err on the side of treating your patient.

But that is only after you have done your job.


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## Paramedic0311 (Nov 4, 2013)

Unless this patient is unable to comprehend reasoning, you need to have a conversation with them on all of the really sick people who have emergencies who's life he/she is putting in danger by dedicating emergency resources no non-emergency habitual calls.  If you keep giving narcs they will keep calling.

If an assessment indicates along with sound judgement, let em have it.


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## FiremanMike (Nov 4, 2013)

It would be virtually impossible to do without turning this into a :censored: swinging contest, but it would be interesting to find out the department run volume and district demographics of the various posters on this thread and to see if there's a correlation between that and their opinion on this scenario.


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## usalsfyre (Nov 4, 2013)

Paramedic0311 said:


> Unless this patient is unable to comprehend reasoning, you need to have a conversation with them on all of the really sick people who have emergencies who's life he/she is putting in danger by dedicating emergency resources no non-emergency habitual calls.  If you keep giving narcs they will keep calling.
> 
> If an assessment indicates along with sound judgement, let em have it.



Your moral obligation is to the current patient, not any potential future patients.


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## usalsfyre (Nov 4, 2013)

FiremanMike said:


> It would be virtually impossible to do without turning this into a :censored: swinging contest, but it would be interesting to find out the department run volume and district demographics of the various posters on this thread and to see if there's a correlation between that and their opinion on this scenario.



I've run just about every system size, volume and demographic out there and it hasn't changed my thought process. This tends to go back to my prior statement that pain management in EMS often seems to be demographically driven rather than patient driven.


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## Christopher (Nov 4, 2013)

FiremanMike said:


> It would be virtually impossible to do without turning this into a :censored: swinging contest, but it would be interesting to find out the department run volume and district demographics of the various posters on this thread and to see if there's a correlation between that and their opinion on this scenario.



It's a good question, I looked at our 2013 numbers YTD:

1172 transported patients.
505 transported patients reported Pain > 0 at first recorded pain level.
97 received a "pain medication" (fentanyl, morphine, toradol, ibuprofen; 155 including adenosine/diltiazem/NTG/atropine/lidocaine/procainamide).

Patients receiving pain medication (n=97, 19.2%)
Average initial VAS: 8.9 (p=<0.0001)
Average final VAS: 5.5 (ns)
Average delta VAS: -3.4 (p=<0.0001)
Pct reporting no change or increased pain: 22.1% (p=<0.0001)

Patients not receiving pain medication
Average initial VAS: 6.6 (p=<0.0001)
Average final VAS: 5.8 (ns)
Average delta VAS: -0.8 (p=<0.0001)
Pct reporting no change or increased pain: 63.4% (p=<0.0001)

Pct Male patients receiving pain medications: 34.6% (p=<0.0001)
Pct Female patients receiving pain medications: 27.5% (p=<0.0001)

Pct White patients receiving pain medications: 19.1% (ns)
Pct Non-White patients receiving pain medications: 18.4% (ns)

Not finished comparing 2012 to 2013, but a YOY increase of 7.1% for patients receiving pain management. The addition of Fentanyl in 2010 tripled the number of patients receiving narcotic analgesia.


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## epipusher (Nov 4, 2013)

Well said usalsfyre


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## Christopher (Nov 4, 2013)

Christopher said:


> It's a good question, I looked at our 2013 numbers YTD:
> 
> 1172 transported patients.
> 505 transported patients reported Pain > 0 at first recorded pain level.
> 97 received a "pain medication" (fentanyl, morphine, toradol, ibuprofen; 155 including adenosine/diltiazem/NTG/atropine/lidocaine/procainamide).



To update, 187 patients received _some_ medication (other than O2, NSS, D50, and LR) AND had a Pain > 0 at first recorded pain level.

Average initial VAS: 8.1
Average final VAS: 5.3
Average delta VAS: -2.8
Pct reporting no change or increased pain: 33.7% (n=63)

Most common patient category with Pain > 0:
Overall: Sick Person (n=90)
No pain control: Sick Person (n=78)
Pain control: Traumatic Injury (n=20)
Any med: Chest Pain (n=54)


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## FiremanMike (Nov 4, 2013)

usalsfyre said:


> I've run just about every system size, volume and demographic out there and it hasn't changed my thought process. This tends to go back to my prior statement that pain management in EMS often seems to be demographically driven rather than patient driven.





epipusher said:


> Well sais usalsfyre



So the below was the described scenario
---
Drive by, pt flags you down, 30-70 yrold states 10/10 sudden onset leg pain, throbbing, constant, non radiating non traumatic. Appears in no distress. Vitals stable, hx irrelevent. Wants to go to hospital, en route says he wants morphine. Same person flags you down everyday for different complain.
---

Vitals stable, does not appear to be in distress, patient flags you down which (to me) implies that he is ambulatory.  Even without the knowledge of this person's previous call history, I would not be inclined to give pain medication either.  I will take this person to the emergency department for further evaluation and treatment.  I don't believe me this makes me judgmental or even prejudiced, but rather I am pulling on my own personal experience as well as the presenting signs and symptoms.

Furthermore, to draw a conclusion that providers who would not universally provide pain medication are judgmental is in and of itself a judgmental position.  To blanketly state that you give everyone pain medication that present with a complaint of pain is the same as saying you give nitro to anyone with chest pain, ignoring all mitigating factors.


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## FiremanMike (Nov 4, 2013)

Christopher said:


> It's a good question, I looked at our 2013 numbers YTD:
> 
> 1172 transported patients.
> 505 transported patients reported Pain > 0 at first recorded pain level.
> ...



Thanks for your stats!  VAS is an acronym for pain scale I assume?  

As for demographics, I was actually referring to urban versus rural versus suburban as well as your overall run volume.  I personally find that race plays almost no factor in my clinical decision making, and certainly would be irrelevant in terms of pain management.


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## Brandon O (Nov 4, 2013)

FiremanMike said:


> To blanketly state that you give everyone pain medication that present with a complaint of pain is the same as saying you give nitro to anyone with chest pain, ignoring all mitigating factors.



What mitigating factors do you have in mind for pain?

I expect we'd all agree that certain comorbid conditions or the patient's physiological status may contraindicate many analgesics. But many folks in this thread (and in the field) seem to be responding to a separate issue, which is that they either don't believe the patient is in pain (_they're lying_), don't believe it's bad enough (_patients should only treatment for very severe pain_), or generally don't believe pain management is important or EMS's responsibility (_not my job_).

In other words, it's more of a philosophical difference, which is why it warrants discussion. There's not much argument over the pharmacological points.


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## FiremanMike (Nov 4, 2013)

Brandon O said:


> What mitigating factors do you have in mind for pain?
> 
> I expect we'd all agree that certain comorbid conditions or the patient's physiological status may contraindicate many analgesics. But many folks in this thread (and in the field) seem to be responding to a separate issue, which is that they either don't believe the patient is in pain (_they're lying_), don't believe it's bad enough (_patients should only treatment for very severe pain_), or generally don't believe pain management is important or EMS's responsibility (_not my job_).
> 
> In other words, it's more of a philosophical difference, which is why it warrants discussion. There's not much argument over the pharmacological points.



To me, in this particular case, the mitigating factors are stable vital signs, (presumed) normal ambulation, and no signs of distress.  I don't feel that these are philosophical issues, but rather these are objective signs that don't seem to be consistent with a patient who is experiencing 10/10 leg pain, which is supposed to be "the worst pain I can imagine".  It is also a mitigating factor to consider that this patient is a known drug seeker who calls daily, but I consider this to be lower on the list because I do agree that even drug seekers can have an episode of legitimate pain.


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## Christopher (Nov 4, 2013)

FiremanMike said:


> Thanks for your stats!  VAS is an acronym for pain scale I assume?



Visual Analogue Scale, 0 to 10 (or 0 to 100 mm). This would be similar to the Wong Baker Faces number line you have kids point to.



FiremanMike said:


> As for demographics, I was actually referring to urban versus rural versus suburban as well as your overall run volume.



We're Suburban/Rural, population of ~20k in our fire district. We're one of 3 ALS units which serve the area (2 county based units). Our call volume will be ~2300 runs this year in total given our forecasts. 90th percentile Call Received to Arrival of ~11 minutes.



FiremanMike said:


> I personally find that race plays almost no factor in my clinical decision making, and certainly would be irrelevant in terms of pain management.



This would be counter to the literature. Females and minorities typically receive less pain control. Apparently my own service has a disparity between males and females (but none for race).


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## DrankTheKoolaid (Nov 4, 2013)

Something I've noticed in my years as Paramedic instructor is students who already work in a 911 system as EMTs come in with a bias already. When I preach pain management to students I get the usual response from them "my partner this, my partner that" so unfortunately this becomes a generational issue also. 

Last cycle I was giving a chest pain scenario where the patient had 3 - 10 C/P. about 3/4 of the students did not give MS after their NTG and when asked why almost all responded with "I can live with the patient being in 3/10 pain". It didn't really click for them until I bluntly pointed out this wasn't about them it's about their patient and can the PATIENT live with it. Thankfully a few light bulbs turned on. There is a reason even ED physicians are are held accountable to answer when A patient has not been given analgesia in the ED In a set time period. We are all human and have formed biases through out life and our own experiences, but they have no place in medicine when treating other human beings.


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## truetiger (Nov 4, 2013)

Bias aside, I think this has more to do about complaints not being supported by exam/objective findings. Would you give any other drug that was not indicated by YOUR findings? I'll give an example, you have an asthma patient that reports shortness of breath. S/He's 100% on room air, has clear lung sounds, is moving good air, and is not breathing with any difficulty. She reports shortness of breath. Are we going to give her a breathing tx?


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## FiremanMike (Nov 4, 2013)

truetiger said:


> Bias aside, I think this has more to do about complaints not being supported by exam/objective findings. Would you give any other drug that was not indicated by YOUR findings? I'll give an example, you have an asthma patient that reports shortness of breath. S/He's 100% on room air, has clear lung sounds, is moving good air, and is not breathing with any difficulty. She reports shortness of breath. Are we going to give her a breathing tx?



This is exactly what I was trying to get at, thanks!


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## Brandon O (Nov 4, 2013)

FiremanMike said:


> To me, in this particular case, the mitigating factors are stable vital signs, (presumed) normal ambulation, and no signs of distress.  I don't feel that these are philosophical issues, but rather these are objective signs that don't seem to be consistent with a patient who is experiencing 10/10 leg pain, which is supposed to be "the worst pain I can imagine".  It is also a mitigating factor to consider that this patient is a known drug seeker who calls daily, but I consider this to be lower on the list because I do agree that even drug seekers can have an episode of legitimate pain.



So in this case, you're falling into either the "patient's lying" or "it's not that bad" (i.e. they're lying about how bad, or they're just a wuss) groups?

There's quite a bit of both literature and common sense suggesting that physical presentations of pain vary tremendously, and presumably we agree that we have at least some responsibility to manage pain. At the same time, there are obviously drug-seeking patients out there, and we may have a responsibility not to feed that (as I alluded above, it's not clear how much responsibility).

So it seems like the real question is where you fall on this spectrum. Granted that if you try too hard not to be fooled, you'll let many people suffer, and if you try too hard to manage pain, you'll support many drug seekers, where along that line do you want to land?

Unfortunately, due to practical obstacles (such as mandated authorization, documentation, QA, and resupply after narc administration), and a common culture/mindset that hates "getting fooled" and generally respects a sort of mountain man self-sufficiency, I think most of us inevitably end up pushed toward the med-sparing side of the spectrum. And since pain that's not of the most obvious sort (sudden and profound, or associated with overt trauma) doesn't jump out to tell us we were wrong, it's not hard to do.


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## DrankTheKoolaid (Nov 4, 2013)

Not exactly the same thing now is it. But to answer your question if coaching didn't help then yes I would and begin to question the validity of my assessment. I treat patients and not machines. Pulse oximetry has a lot of variables that can affect it including lag. But then again I would also want to look at Etco2 waveform as I don't trust SPO2 as far as you can throw it.


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## Brandon O (Nov 4, 2013)

truetiger said:


> Bias aside, I think this has more to do about complaints not being supported by exam/objective findings. Would you give any other drug that was not indicated by YOUR findings? I'll give an example, you have an asthma patient that reports shortness of breath. S/He's 100% on room air, has clear lung sounds, is moving good air, and is not breathing with any difficulty. She reports shortness of breath. Are we going to give her a breathing tx?



As an asthma patient who has often experienced mild shortness of breath without overt wheezing, I hope you would. It is not much fun.

I know we all understand that symptoms are not things you can detect from the outside (that's their definition; otherwise we'd call them signs). So this seems to come back to the issue of whether you think they're actually experiencing bronchospasm (or pain, for the original topic). It's sensible to wonder whether the pathogenesis is something different if you're not noting physical findings you would otherwise expect. But if that dilemma isn't on the table (e.g. there's no question of CHF, anxiety, etc), and deep down, what you're really asking is "is he REALLY short of breath/in pain?"), then we should be able to acknowledge that we're merely debating whether the patient's lying to us. And as I said, that only matters if we decide we're responsible for some sort of gate-keeper duty. (For narcs, maybe. For albuterol, ehh...)


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## truetiger (Nov 4, 2013)

No, he falls into the category that does a proper assessment. It is imperative to be able to match complaints/findings and see what holds water and what doesn't. This has more to do with just narcs. Some of us work in systems that your transport decision is made by a good assessment.


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## Ewok Jerky (Nov 4, 2013)

truetiger said:


> Bias aside, I think this has more to do about complaints not being supported by exam/objective findings. Would you give any other drug that was not indicated by YOUR findings? I'll give an example, you have an asthma patient that reports shortness of breath. S/He's 100% on room air, has clear lung sounds, is moving good air, and is not breathing with any difficulty. She reports shortness of breath. Are we going to give her a breathing tx?



The problem with your analogy is that pain does not have physical findings like other diseases such as asthma.  Take for example Shingles.  The pain is originating in the sensory nerve itself and patients can experience sever pain for days before any rash shows up.

also- Remember that narcs aren't the only way to treat pain. Could this be a cause of some the differing opinions we are experiencing here? I know a lot of services only stock narcs and benzos but I am thinking big picture here with pain management.


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## truetiger (Nov 4, 2013)

So are you saying that the verbal pain scale is our only assessment tool when it comes to pain? And is the only determinant in pain management?


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## Christopher (Nov 4, 2013)

beano said:


> also- Remember that narcs aren't the only way to treat pain. Could this be a cause of some the differing opinions we are experiencing here? I know a lot of services only stock narcs and benzos but I am thinking big picture here with pain management.



Our pain control protocols are pretty broad in terms of the tool we may use, ranging from ASA/tylenol/ibuprofen to toradol to narcotics to antihistamines to benzos.


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## chaz90 (Nov 4, 2013)

truetiger said:


> I'll give an example, you have an asthma patient that reports shortness of breath. S/He's 100% on room air, has clear lung sounds, is moving good air, and is not breathing with any difficulty. She reports shortness of breath. Are we going to give her a breathing tx?



I sure would, or at least think about it. After ruling out other potential causes for the SOB and the patient telling me this feels like asthma and her inhaler typically fixes it, I'd give some albuterol a try. 

This seems to correlate fairly well with a common nebulous pain control scenario. How about a frequent patient who complains of 10/10 abdominal pain? Says it feels like pancreatitis and that Dilaudid typically helps him when administered at the ED. We don't see textbook outer signs of "severe" pain, but he winces visibly when moved and quickly comes back to complaining about the pain if briefly distracted. Similar to our SOB patient above, none of our assessments reveal anything remarkable, but I would likely choose to medicate this patient anyway.

We do this all the time with another common patient. Think of our chest pain calls. How many of them do we go exclusively off of patient reported symptoms without any directly objective signs? 60 YOM, frequently calls complaining of chest pain. 5/10 dull chest pressure for the past two hours, non reproducible, and radiates to the arm and neck. Other evaluations at the ED for what seem to be identical complaints have never revealed any cardiac event. 12 Lead EKG and vital signs are all stable. How do we treat this patient? Why, based on subjective symptoms alone, this patient would be treated for suspected ACS by any competent EMS provider.

How different is this really from treating pain based solely on subjective symptoms? No where in my job description does it say that I was hired to be a stingy gatekeeper hoarding access to narcotic analgesia. I maintain accurate records and treat only when indicated, but I don't think we should get caught up in thinking of pre-hospital opioid use any differently than other medications we carry. 

In my mind, desire to do our part to prevent drug abuse and addiction needs to come second to our primary responsibility to patient care. I've treated patients with admitted opioid addictions for pain before, and I'll do it again. I'm certain I've been tricked before, and quite frankly, I'm not overly bothered by it. I don't control access to all legal and illegal drugs, and all I can do with many of my medications is treat people based on what they tell me.


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## Ewok Jerky (Nov 4, 2013)

truetiger said:


> So are you saying that the verbal pain scale is our only assessment tool when it comes to pain? And is the only determinant in pain management?



Pretty much yes.  Objective findings are useful in Dxing the etiology of the pain.  Plenty of things that cause pain can be managed non-pharmacologically.  But when someone is sitting in front of me and tells me they are in pain, I can neither rule in or out the fact they are in fact experiencing pain.  All I have is their word.


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## epipusher (Nov 4, 2013)

These replies help to maintain my faith that the majority of providers are true professionals.


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## FiremanMike (Nov 4, 2013)

... disregard this one..


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## FiremanMike (Nov 4, 2013)

epipusher said:


> These replies help to maintain my faith that the majority of providers are true professionals.



Given your fervent argument towards pain control in this particular scenario, I can only assume that your somewhat vague statement here would indicate that you feel anyone who wouldn't give pain management to this patient would fall under the category of "not a true professional".

I would appreciate it if you could expand on that, as I feel that the rationale for not giving pain medication to this particular patient (barring no other assessment findings which weren't reported in the initial post) were solid and based on sound clinical judgement.


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## Rialaigh (Nov 4, 2013)

Let me throw a wrench in this scenario. 

In the state I work in we have to call for a physician to the radio to request to give narcotics, every time. The ER is a 36 bed ER staffed by two physicians and a PA, the physicians manage 30 of the beds. There are generally people in the waiting room and the ER is full from 11am to roughly 3am or later. 

If I am calling for pain management and having to take a physicians time away from an already full and busy ER with average transport times of less than 20 minutes I am not real inclined to do that minor pain, non descript pain, and frequent fliers with repeat complaints.

Would having to call for online orders for all pain management change your concepts on who you would or wouldn't treat?


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## chaz90 (Nov 4, 2013)

Rialaigh said:


> Would having to call for online orders for all pain management change your concepts on who you would or wouldn't treat?



Ugh. What a horrific policy. This actually wouldn't change what I did though. On the contrary, I would hope that my (and others like me) frequent calls for pain control orders would gradually convince someone higher up that this protocol needed to be changed. If many medics are reluctant to call in for orders, there may not seem to be an impetus to change a hopelessly outdated policy such as this.


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## Christopher (Nov 4, 2013)

Rialaigh said:


> Would having to call for online orders for all pain management change your concepts on who you would or wouldn't treat?



The literature shows that any barrier (money, paperwork, etc) to a treatment reduces the usage of the treatment. This is well known to many other industries/fields.

Here is a gem from a protocol, which you may find interesting in comparison to your system:

"In all protocols, the instructions which state "notify destination or contact medical control" is satisfied in our system by contacting the receiving hospital at the appropriate time. We have no restriction to contact medical control prior to administering any treatments in subsequent boxes. Obviously, if you need to contact medical control at any time for patients with unusual presentations, high risk refusals, or any other unusual circumstances, please continue to do so."


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## usalsfyre (Nov 4, 2013)

Rialaigh said:


> Let me throw a wrench in this scenario.
> 
> In the state I work in we have to call for a physician to the radio to request to give narcotics, every time. The ER is a 36 bed ER staffed by two physicians and a PA, the physicians manage 30 of the beds. There are generally people in the waiting room and the ER is full from 11am to roughly 3am or later.
> 
> ...



I'll say it again...your obligation is to your CURRENT patient...not anyone else's or any future patients. "Oh I'm taking up valuable time" is weak.


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## usalsfyre (Nov 4, 2013)

FiremanMike said:


> Furthermore, to draw a conclusion that providers who would not universally provide pain medication are judgmental is in and of itself a judgmental position.


Yep it absolutely is. There's NOTHING wrong with being judgmental no matter what the current PC theory is, judgement exist to aid in decision making. Part of my JOB is to be judgmental. What's not ok is withholding an indicated medication based on demographic (age, race, weight, gender, socioeconomic status, frequency of contact, ect). 



FiremanMike said:


> To blanketly state that you give everyone pain medication that present with a complaint of pain is the same as saying you give nitro to anyone with chest pain, ignoring all mitigating factors.


While I don't go down the cardiac treatment pathway for every CP patient all of them get a 12 lead EKG because it's indicated and benign. Despite what medic school TRIES to convince us of, narcs are one of the more benign drugs we carry.

Perhaps it's because we carry several non-narcotic options I don't see why you can't medicate this guy in some way.


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## FiremanMike (Nov 4, 2013)

usalsfyre said:


> Yep it absolutely is. There's NOTHING wrong with being judgmental no matter what the current PC theory is, judgement exist to aid in decision making. Part of my JOB is to be judgmental. What's not ok is withholding an indicated medication based on demographic (age, race, weight, gender, socioeconomic status, frequency of contact, ect).
> 
> 
> While I don't go down the cardiac treatment pathway for every CP patient all of them get a 12 lead EKG because it's indicated and benign. Despite what medic school TRIES to convince us of, narcs are one of the more benign drugs we carry.
> ...



I believe I pretty clearly spelled out why I wouldn't give pain medication to this patient, and the only demographic considered by your list (frequency of contact) was far down the list and far less important than clinical assessment findings.  I was pretty clear on that..

12 lead is an assessment tool, morphine and nitro are treatments.  I'm not sure I understand your comparison?


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## VFlutter (Nov 4, 2013)

PFDEMT said:


> 1-- if a guy that is 30 looks 70 odds are drugs aged him:censored:



Oh really? You obviously have not taken care of many chronically ill patients. When I have a young cachectic patient I do not assume they are a drug addict.


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## Brandon O (Nov 4, 2013)

beano said:


> But when someone is sitting in front of me and tells me they are in pain, I can neither rule in or out the fact they are in fact experiencing pain.  All I have is their word.



Right. So you sort of have to decide ahead of time -- and even if you don't sit down and do it explicitly, you are still deciding -- whether, by and large and within reason, you're going to trust their word or you're not. Because neither before, during, or after are you likely to get objective evidence to "confirm" someone's pain.

This has nothing to do with decisions that can be made based on objective findings. But usually pain isn't like that, unless we manage to fool ourselves into thinking we're smarter than we are ("bah, people don't look like that when they're hurting"). So that decision won't be based on the patient, it'll be based on the kind of provider you want to be. Do you want your sin to be giving pills to addicts or standing by while someone suffers?

I would prefer to lean toward the former, but I'm actually not arguing that everyone should agree. I am saying that we should acknowledge we're making that choice, though, and it's based on nothing but our personal ethics and worldview.


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## Akulahawk (Nov 4, 2013)

Brandon O said:


> Right. So you sort of have to decide ahead of time -- and even if you don't sit down and do it explicitly, you are still deciding -- whether, by and large and within reason, you're going to trust their word or you're not. Because neither before, during, or after are you likely to get objective evidence to "confirm" someone's pain.
> 
> This has nothing to do with decisions that can be made based on objective findings. But usually pain isn't like that, unless we manage to fool ourselves into thinking we're smarter than we are ("*bah, people don't look like that when they're hurting*"). So that decision won't be based on the patient, it'll be based on the kind of provider you want to be. Do you want your sin to be giving pills to addicts or standing by while someone suffers?
> 
> I would prefer to lean toward the former, but I'm actually not arguing that everyone should agree. I am saying that we should acknowledge we're making that choice, though, and it's based on nothing but our personal ethics and worldview.


What a great point you brought up!

It's amazing what happens when you find someone who is in sickle-cell crisis who says they're in 10/10 pain and they're sitting there playing video games... you think this is someone that's not in pain because they don't "look" like they're in pain. It's not that they aren't, rather they have lived with it for so long that they don't display it like the rest of us normally would. A "comfortable level of pain" for that person might be a 6/10.


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## Rialaigh (Nov 4, 2013)

If anyone is wondering it is SC state law (or SC state EMS protocol) that you cannot give a controlled substance (morphine, nubaine) without online medical control. It is not an agency problem, it is statewide. 



usalsfyre said:


> Yep it absolutely is. There's NOTHING wrong with being judgmental no matter what the current PC theory is, judgement exist to aid in decision making. Part of my JOB is to be judgmental. What's not ok is withholding an indicated medication based on demographic *(age, race, weight, gender, socioeconomic status, frequency of contact, ect).*
> 
> 
> While I don't go down the cardiac treatment pathway for every CP patient all of them get a 12 lead EKG because it's indicated and benign. Despite what medic school TRIES to convince us of, narcs are one of the more benign drugs we carry.
> ...



Demographic is a very reliable tool to add to the box that helps us determine the seriousness of a problem or if a patient is "sick" or not. 

All 6 of the criteria that you listed for demographics do make a difference in the frequency of occurrence and presentation for various diseases. I could give you examples backed with studies for all of those. Demographics need to be a part of your decision making process. I can give you reasons to give meds and reason to withhold meds based on demographics.




usalsfyre said:


> I'll say it again...your obligation is to your CURRENT patient...not anyone else's or any future patients. "Oh I'm taking up valuable time" is weak.



This is a whole different discussion but when you talk about an ER physician or a ER nurse their job is constant triage and treatment of dozens of patients at a time. I am not going to be inconsiderate of that ER physicians time by taking his time away from his other patients unless my patient really needs pain medication. The same reason I don't demand my "toothache" patient go to a code room immediately instead of triage...it may be my only patient currently but it is one of 50-80 patients in the ER at the time I bring them.


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## Carlos Danger (Nov 4, 2013)

Brandon O said:


> Right. So you sort of have to decide ahead of time -- and even if you don't sit down and do it explicitly, you are still deciding -- whether, by and large and within reason, you're going to trust their word or you're not. *Because neither before, during, or after are you likely to get objective evidence to "confirm" someone's pain.*
> 
> This has nothing to do with decisions that can be made based on objective findings. *But usually pain isn't like that, unless we manage to fool ourselves into thinking we're smarter than we are* ("bah, people don't look like that when they're hurting").
> 
> ...



Excellent, excellent, excellent points. Pretty much sums up this entire thread, if you ask me.

Obviously there is always discretion involved - and I'm not saying I would have medicated the patient in the OP's scenario - but anyone who refuses to give analgesia without "objective evidence" of pain will absolutely be guilty of under-treating for pain.


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## usalsfyre (Nov 4, 2013)

FiremanMike said:


> I believe I pretty clearly spelled out why I wouldn't give pain medication to this patient, and the only demographic considered by your list (frequency of contact) was far down the list and far less important than clinical assessment findings.  I was pretty clear on that..
> 
> 12 lead is an assessment tool, morphine and nitro are treatments.  I'm not sure I understand your comparison?



Ok, a better comparison would be I administer the vast majority of non-traumatic CP patients ASA (assuming no overt contraindications) regardless of suspected origin based on the fact there's little chance of harm and the benefit is relatively great. I think you'll find it's not unusual in EM.

What's your risk of using an indicated medication? What's your chance if harm? Why do so many organizations in healthcare make pain management a benchmark? Why do EM docs typically discharge someone with a script for meds EVEN IF it's not a narcotic option.

I'm not advocating 4mgs of Dilaudid for everyone. But why is 500 of APAP, 30 of ketorolac or 400 of ibuprofen such a problem if the patient is complaining? The "physical assessments" you use are not considered reliable by anyone else...what makes you special?


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## usalsfyre (Nov 4, 2013)

Rialaigh said:


> If anyone is wondering it is SC state law (or SC state EMS protocol) that you cannot give a controlled substance (morphine, nubaine) without online medical control. It is not an agency problem, it is statewide.
> 
> 
> 
> ...



I have a background in the ED as well as on an EMS unit. I get flow. I get triage, to the point I've DONE ED triage before. So I'll say this.

You are not an EM doc, or ED nurse. You are a paramedic and therefore have an ethical obligation to ONE patient. ONE. Other patients in the ED or the ED staff's time are not your concern. If I heard this excuse for withholding analgesia out of any of my providers my response would be in writing and stay in their file for a year. Flow and dispo are vitally important and we should do everything we can to assist it, but not at the expense of the patient you are responsible for.

All of those demographic factors should play into assessment except for one. If you're basing ANYTHING on number of contacts you're an idiot who's going to get bit in the butt by it. You will very, very lucky if complacency causes a non-fatal event and lucky if it's only fatal for the patient. DO NOT get complacent in any portion of this job.

As for the others, yes they play in but not ONE of those holds any weight for withholding meds. Detecting atypical presentation, recognizing tendency for being stoic..maybe. But not withholding.


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## FiremanMike (Nov 4, 2013)

usalsfyre said:


> Ok, a better comparison would be I administer the vast majority of non-traumatic CP patients ASA (assuming no overt contraindications) regardless of suspected origin based on the fact there's little chance of harm and the benefit is relatively great. I think you'll find it's not unusual in EM.
> 
> What's your risk of using an indicated medication? What's your chance if harm? Why do so many organizations in healthcare make pain management a benchmark? Why do EM docs typically discharge someone with a script for meds EVEN IF it's not a narcotic option.
> 
> I'm not advocating 4mgs of Dilaudid for everyone. But why is 500 of APAP, 30 of ketorolac or 400 of ibuprofen such a problem if the patient is complaining? The "physical assessments" you use are not considered reliable by anyone else...what makes you special?



My unmentioned physical assessments aren't considered reliable by anyone else, or the physical assessments that I've not described aren't considered reliable by those here who advocate throwing narcotics at everyone despite consideration of the presence (or lack thereof) of physical findings and without considering the presence (or lack thereof) of mitigating factors. 

There have been so many special circumstances thrown about throughout this thread that aren't relevant to the original situation, and when present would definitely alter my decision making product.  People continue to add it snippets of things that _could be_ wrong with this patient, and are ignoring the notion that those might be discovered and considered during the assessment.  Had they been mentioned as assessment findings during the original post, would have altered the decision making path.  Because they weren't, and this patient is imaginary, it's safe to assume they are negative findings and warrant no further consideration.

Additionally, you made a previous statement that the patient at hand is the only one worthy of consideration at the moment and this notion is patently false in healthcare of 2013.  Does a chronic pain patient really need to be transported by EMS to the ED, saturating those resources daily, or would society as a whole be best served if we could assist them in getting to a chronic pain doc who can more appropriately manage them?  Don't jump to the conclusion that I refuse to transport pain patients, but I have been making efforts lately to help patients reach more appropriate means of treatment as opposed to just blindly taking everyone to the ER.  We're now talking about the community paramedic ideas that are floating around, and if what I'm hearing is true, they will be the norm very soon.  ***ETA - I don't use this thought process all inclusively wheen considering pain management, and may not be totally relevant to the discussion of pain control for this patient, but it needed to be said.***

Finally, it may interest you to note that the local ERs here are actually being much more stringent about treating nonspecific, non verifiable pain, but then again I am very fortunate to work in a progressive area..


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## Aidey (Nov 4, 2013)

usalsfyre said:


> But why is 500 of APAP, 30 of ketorolac or 400 of ibuprofen such a problem if the patient is complaining? The "physical assessments" you use are not considered reliable by anyone else...what makes you special?



I'm going to go with because probably less than 5% of EMS agencies in the US carry even one of those options. 

Is that right? No, it isn't. But is that part of the reason that pain complaints are under-medicated? Hell yes.


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## Christopher (Nov 4, 2013)

Aidey said:


> I'm going to go with because probably less than 5% of EMS agencies in the US carry even one of those options.
> 
> Is that right? No, it isn't. But is that part of the reason that pain complaints are under-medicated? Hell yes.



If my podunk USA fire department has all 3 of those, anybody can.

Hell my industrial fire brigade carries all but the toradol (and if we were EMT-I level we'd carry and give it...).


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## chaz90 (Nov 4, 2013)

Christopher said:


> If my podunk USA fire department has all 3 of those, anybody can.
> 
> Hell my industrial fire brigade carries all but the toradol (and if we were EMT-I level we'd carry and give it...).



Agreed, but that doesn't seem to be the consensus of many medical directors. Protocol is statewide here and decided by a committee that makes significant changes only by a near act of God as far as I can tell. I'm not defending this thought, but I think many who write protocols figure "If the pain isn't severe enough for opioids, it can wait until they arrive at the ED."


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## Rialaigh (Nov 4, 2013)

FiremanMike said:


> My unmentioned physical assessments aren't considered reliable by anyone else, or the physical assessments that I've not described aren't considered reliable by those here who advocate throwing narcotics at everyone despite consideration of the presence (or lack thereof) of physical findings and without considering the presence (or lack thereof) of mitigating factors.
> 
> There have been so many special circumstances thrown about throughout this thread that aren't relevant to the original situation, and when present would definitely alter my decision making product.  People continue to add it snippets of things that _could be_ wrong with this patient, and are ignoring the notion that those might be discovered and considered during the assessment.  Had they been mentioned as assessment findings during the original post, would have altered the decision making path.  Because they weren't, and this patient is imaginary, it's safe to assume they are negative findings and warrant no further consideration.
> 
> ...




The local ER has a chronic pain policy now. ER physicians are not allowed to prescribe or give narcotics to frequent fliers deemed pain seekers without OBVIOUS cause of pain. This was brought down from the state level to implement at many hospitals to try and curb frequent fliers from tying up resources. Now patients are explained that they can come back every day for the next week but no physician in the ER will give them a narcotic. 

I don't know of a single EMS agency in my area that carries anything other than morphine and fent. I would be all over giving everyone some sort of pain management if we could have some non narcotic alternatives. 


Also as to the comment about using number of visits or number of calls as part of your assessment. It does not replace a good physical assessment but frankly I consider it to be one of the most important parts of a history. If the patient is complaining about flank pain, and I know they have called EMS 30 times for this complaint and the ER has never found a kidney stone...I am betting the chances of a kidney stone now are pretty slim....the chances of a real emergency (while still possible) are even slimmer...


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## Carlos Danger (Nov 5, 2013)

usalsfyre said:


> I'm not advocating 4mgs of Dilaudid for everyone. *But why is 500 of APAP, 30 of ketorolac or 400 of ibuprofen such a problem* if the patient is complaining?



Because this discussion seems to be about whether or not analgesia is really indicated at all in the patients in question. 

And if analgesia isn't necessary because you suspect that the patient is faking or whatever, then a non-narcotic drug is no more appropriate than a narcotic one. 



Aidey said:


> I'm going to go with because probably less than 5% of EMS agencies in the US carry even one of those options.
> 
> Is that right? No, it isn't. *But is that part of the reason that pain complaints are under-medicated? Hell yes.*



I don't know about that. I think the reason those non-narcotic analgesics are pretty uncommonly used in EMS is because they just aren't great drugs for EMS use. 

They aren't suitable as sole agents severe pain, which is what we are most concerned about in EMS. In some cases they can only be administered PO, which is a clear disadvantage or contraindication in many situations. They take a very long time to reach peak-effect, even in the IV forms. And finally, a good argument can be made that in a sick patient, these drugs carry even more considerations and implications than opioids do. 

I'm not saying that non-narcotic analgesics have no place in EMS, just that the situations where they are a better choice than opioids are very few. If that weren't the case, they would be more widely used.  



chaz90 said:


> I think many who write protocols figure *"If the pain isn't severe enough for opioids, it can wait until they arrive at the ED."*



Personally, I think that is a reasonable sentiment. Severe pain is an emergency, but lesser pain is not. I don't think it's practical for necessary or possible for EMS to try to make everyone pain-free. With a typical transport time of 30 minutes or so, your patient would probably already be in the ED for quite a while before the non-narcotic even reached full effect.


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## jwk (Nov 5, 2013)

usalsfyre said:


> Further, few paramedics actually delve into chronic pain, ect, and when they do it's an excuse to WITHHOLD meds rather than administer.



Chronic pain is really not an EMS issue.  

Chronic pain patients can be on any number or combination of medications to treat their chronic pain.  There are a lot of creative combinations out there with non-narcotic meds such as pregabalin, gabapentin, and some anti-seizure meds that interrupt some pain perception pathways.  In addition, there are those who are using long acting narcotics including fentanyl patches and impressive doses of oxycontin.  These are not patients that need a paramedic second guessing the pain management plan already in place for a given patient and adding narcotics to the mix just because the patient says they're hurting.


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## triemal04 (Nov 6, 2013)

Brandon O said:


> In other words, it's more of a philosophical difference, which is why it warrants discussion. There's not much argument over the pharmacological points.


It's not a philosophical difference at all.  Either people are willing and able to perform their job as a medical provider, which means determening what treatements, if any, are needed before giving them...or they aren't.  Some people we see, no matter what the problem is, need immediate treatement...some don't.  Some need things we don't carry...some do.  That determination needs to be made for every patient, every time.    


DrankTheKoolaid said:


> There is a reason even ED physicians are are held accountable to answer when A patient has not been given analgesia in the ED In a set time period.


Yes, it's called patient satisfactions surverys (PG scores) and profits; don't fool yourself into thinking that is being done soley for altruistic reasons.


Akulahawk said:


> It's amazing what happens when you find someone who is in sickle-cell crisis who says they're in 10/10 pain and they're sitting there playing video games...


This is something that everyone needs to be very careful with; pt's with chronic, longstanding pain problems.  This is where having them treated by a reputable pain specialist is vital, and where sitting down with one could pay off for a lot of paramedics.  The goal isn't neccasarily to make the patient "pain free" but to get them to a point where they can go about their daily activities of living without issue and function normally; ie to lead a regular life.  If someone is still fulfilling all those things despite complaining of increased pain, an immediate dose of anything likely is not needed, and may not be in the patient's best interest.

This topic, like so many others is pointless.  There are far to many people who think that they have "been there done that," know everything, and let singular personal experiences reflect on their view of other providers and view of what is appropriate.


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## Leal271 (Nov 9, 2013)

Unforunately if you have the belief someone is a "drug seeker" you may not do whats best for the *PATIENT*. Do a good assessment, and treat your patient.


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## coolidge (Nov 10, 2013)

*prescription monitoring program (PMP)*

The appropriate emergency staff practitioner can access your state's prescriptiom monitoring program (PMP) data bank.
The data bank will provide a historical picture of controlled substance prescriptions acquisitions.
Also, some hospitals, and several states, are developing a system of sharing medical histories, which identify patient's history of ER usage, etc.


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## TheLocalMedic (Nov 10, 2013)




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