# Physicians' Impression of Pre-Hospital Pain Management



## redcrossemt (Nov 27, 2009)

Patient Summary: 26 y/o female with worsening left flank pain over the past 3 days. It has been a 2-3 out of 10, just kind of achy; but this morning is a "20" out of 10, woke patient out of her sleep, and she couldn't get back to sleep because of the pain. Patient was tachycardic, tachypneic, wincing, and generally appeared to be in distress. Interventions included 1.5 mcg/kg of fentanyl IV. Our transport time was about 8 minutes.

After patient care had been transferred and report given to nursing staff, the ER physician took me aside and asked me why I had given fentanyl to this particular patient. I reiterated the story above, emphasizing that the patient said she was in severe pain, and appeared to me to be in distress. I also reiterated our pain management protocol, and that the pre-hospital standard of care now includes pain relief. The physician seemed very upset with this, stating that it impaired her assessment of the patient, and that the "ride over here was only 8 minutes" and the patient could wait for pain medicine. She even said that us giving pain medicine makes their "2mg of morphine seem not so great" to the patient.

I tried to answer all of her concerns to the best of my ability. I emphasized the short half-life of fentanyl, the results of my initial physical exam that were completed before pain medicine, that 8 minutes of pain is still 8 minutes of pain, and that the effectiveness of their morphine should only be based on the patient's pain relief. I also tried to bring up the fact that our protocols (for the entire regional system) are based on ER physician recommendations from all of the area hospitals and that she could participate in the working group if she'd like to make recommendations.

In any case, the physician ended up walking away from me in mid-conversation, with nothing resolved.

I have worked with lots of partners who show resistance to treating pain (you all know the type... "the patient doesn't deserve the pain meds", "it's a short trip", etc...) but I have yet to experience this resistance with physicians or hospital staff.

My question to everyone is, does pain medicine actually interfere with physician assessment, should we not be providing pain relief to unknown abdominal/side pain patients, and have you had physician resistance to pain management protocols? And any advice for handling this physician (who has told us before to not start IVs on patients, even those in need of ALS, so they can go out to external triage - aka 'the lobby')?


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## rescue99 (Nov 27, 2009)

redcrossemt said:


> Patient Summary: 26 y/o female with worsening left flank pain over the past 3 days. It has been a 2-3 out of 10, just kind of achy; but this morning is a "20" out of 10, woke patient out of her sleep, and she couldn't get back to sleep because of the pain. Patient was tachycardic, tachypneic, wincing, and generally appeared to be in distress. Interventions included 1.5 mcg/kg of fentanyl IV. Our transport time was about 8 minutes.
> 
> After patient care had been transferred and report given to nursing staff, the ER physician took me aside and asked me why I had given fentanyl to this particular patient. I reiterated the story above, emphasizing that the patient said she was in severe pain, and appeared to me to be in distress. I also reiterated our pain management protocol, and that the pre-hospital standard of care now includes pain relief. The physician seemed very upset with this, stating that it impaired her assessment of the patient, and that the "ride over here was only 8 minutes" and the patient could wait for pain medicine. She even said that us giving pain medicine makes their "2mg of morphine seem not so great" to the patient.
> 
> ...



Sounds like a walking lawsuit.  So much for higher education, eh?


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## Shishkabob (Nov 27, 2009)

First point:  Tough luck to the physician.  You're working under your med directors license, not hers.  If she doesn't like how something is done and it's in accordance to what your MD accepts, tough noogies, it's not her call.  Doesn't want an IV?  Start one if you deem necessary.  If she keeps complaining, ask her if she's willing to be co-named on the lawsuit for not providing an IV to someone who needed it.  



As far as pain control for abd pain, I've spoken to a few Docs and PAs on the matter and they are all pretty much in agreement:  Pain meds should not make or break their diagnosis, and should not slow down their assessment.  If you deem your pt needs pain control, then do pain control.


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## WolfmanHarris (Nov 27, 2009)

The clinical guidelines I've read for even abdo pain (classically the pt's that had analgesics withheld) specifically state that pain management does not and should significantly interfere with assessment and in fact, management of pain may make assessment easier as the pt. can focus on and answer questions with regards to their symptoms.

It's unfortunate that such a dated attitude still exists among professionals. Sure we don't want to "snow" our pt.'s, but we can still manage their pain. At the very least titrate for a more manageable pain level.


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## Seaglass (Nov 27, 2009)

Luckily for me, I'm not on the hook for any pain management decisions my medic makes. But we keep running into one receiving physician who we just can't win with. If we gave pain relief, we're screwing up his assessment. If we didn't--even when the patient doesn't want drugs--we're abusing the patient.


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## redcrossemt (Nov 27, 2009)

WolfmanHarris said:


> ...pain management does not and should significantly interfere with assessment...



Does anyone have any research or references for this?


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## FFMedic75 (Nov 27, 2009)

One of the main reasons Fentanyl is becoming the prehospital standard of care for pain management is it's short 1/2 life.  It gives the crew the ability to transport the patient comfortably and wear off shortly after arrival at the ED, thus allowing the Doc to evaluate the patient.  We as paramedics exist not only to treat cardiac arrests, but to prevent patients from suffering through excruciating pain while they are in our care.


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## cm4short (Nov 27, 2009)

During my internship; Experienced an learning situation similar but not similar to this one. Basically it was on the use of pain medication for abdominal pain. I'm sure it applies to this patient also.

The article I used involved MS for pain management. But the overall goal is the same. Pain therapy is both prudent and humane to take the edge off (without eliminating pain), in order to reduce the discomfort. Also, the physical assessment alone is not used to diagnose the patient due to the advancement in modern medicine. 

View attachment morphinesulfate.pdf

The last portion of this file gives an excellent explanation.


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## EMSLaw (Nov 27, 2009)

Not being a medic, I can't really comment on pain management, other than to say that I have frequently wished there was something I could do for a patient who was in pain.  It's a good 15-20 minutes on bumpy roads to a hospital around here, and even the medics generally don't give anything for pain.  When you have to lift the patient, put them on the stretcher, load them, and then get them to the hospital, it would be nice - both for me and the patient - if they weren't intermittantly screaming in pain.  

And yes, I try to be as gentle as I can, but moving someone with a broken or severely dislocated bone will be painful no matter what I do.


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## MrBrown (Nov 27, 2009)

I agree that prehospital analgesia is very important and that patients need to recieve adequate analgesia.

That said, lets say this patient was 50kg (50mcg of fentanyl at 1mcg/kg) is equivalent to 5mg of morphine.  If she was 50g at this guy'd dose of 1.5mcg/kg that's like 7.5mg of morphine.  

If this were me .... I might give her oh, 2mg and titrate up to maybe 5.

I can sort of see where this doc might be a bit pissed I mean was this patient spun off into lalaland or did she tolerate the fentanyl quite well?  I mean in general I'll that physicians who think ambo's should not be giving pain relief are idiots *but* if ambo gets thier patient so wasted they can't participate in exam or treatment then yeah, fair enough.


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## redcrossemt (Nov 27, 2009)

MrBrown said:


> I agree that prehospital analgesia is very important and that patients need to recieve adequate analgesia.
> 
> That said, lets say this patient was 50kg (50mcg of fentanyl at 1mcg/kg) is equivalent to 5mg of morphine.  If she was 50g at this guy'd dose of 1.5mcg/kg that's like 7.5mg of morphine.
> 
> ...



I'm not questioning you, but have you ever used fentanyl before? I know they say that fentanyl is 100 times more powerful than morphine, but I've never seen 100mcg of fentanyl compare to the analgesia or sedation properties of 10mg of morphine. In fact, our region's maximum dose increased from 2mcg/kg to 3mcg/kg because we weren't always getting adequate analgesia from 2mcg/kg doses, and the drug was proven to be safe, effective, and well-utilized among paramedics in our region.

Patient in said scenario weighed 60kg. She initially got 60mcg, and got another 30 mcg when her pain was not relieved by the first dose after 10 minutes or so. She tolerated it well and wasn't "wasted" or unable to participate in a continued exam or treatment.


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## karaya (Nov 27, 2009)

Here is a good article about Fentanyl and I thought this line from the article punctuates the OPs issue about ED docs arguing that their assessment his hindered by the use of Fentanyl.

"Also, its short duration of action would appear to be ideal for agencies that still have difficulty with emergency physicians who chastise use of narcotics that may mask symptoms of pain and hide illness or injury despite the overwhelming scientific opinion in the peer-reviewed medical literature that this is a myth."

http://www.emsresponder.com/features/article.jsp?id=6016&siteSection=16


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## NJnewbie (Nov 28, 2009)

Just curious, did you ever find out what was the cause of the pain?  I'm thinking it was a kidney stone.  I had one and had the same symptoms.  They are VERY painful.


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## mycrofft (Nov 28, 2009)

*Matter of fashion and commonsense*

1970s: pain meds available at the time would obtund the pt, depress resps. Prehospital analgesia was very limited, second tiered to life support and spinal/ortho stabilization. USe of nitrous oxide suggested.
1980's: much the same. Newer drugs becoming available, paramedics given more latitude using protocols (versus everything by radio order).
1990's: Continuation of 1980's trends. Quality assurance measures increase, including patients having a greater say. Pain control becoming an issue.
2000's: "Pain Control" becomes big time issue, many practitioners ordering scheduled drugs on pt demand. OD's and additions upswing due to use/abuse of valid prescriptions.

Follow your protocols when they do not damage the patients or obtund them. I'd suggest doing your manipulations and spine boarding etc before meds because pain can be the sign you are doing something wrong, and if it is masked you might drive into the ER and find that foreign object in their back, or undx'ed fx that pain would have divulged. Ther's always going to be someone with a bone to pick, just document like crazy and keep an open mind.


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## triemal04 (Nov 28, 2009)

I wouldn't worry to much about it at this point.  "Masking" symptoms with analgesics and creating problems with further assessment has for the most part been shown to be a falsehood; apparently this MD either isn't comfortable with her assessment, still holds to the old belief and not current trends, or doesn't like what you are doing prehospital.  The comment about making their treatments seem "not so great" is particularly disturbing.  Either way, what you did, including your explanation was the right thing to do.  If this continues to be a problem it might be something that needs to be brought up (tactfully) with your medical director, but otherwise, keep treating your pt's like you're doing.


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## johnrsemt (Nov 30, 2009)

My old medical director gave a great explanation on pain management:

    He said that in the near past doctors needed the patient totally awake and feeling everything so that the doctor could do a hands on exam:  palpatating the abd for kidney stones or r/o appendix.  But it wasn't always accurate, if a patients abd hurts, they would say it hurt no matter where they were pushed on.
    Now doctors use CT scans to rule them out, and the patient is ok to be "snowed" by pain meds;   or just happily pain free.

   We were told that if our patient had stubbed their toe, and had a pain level over 3/10 to make it go away by the time they got to the hospital.

   And to the earlier poster, yes it is great if your patient doesn't scream every time you touch them.    I always hated that when I was BLS,.  I had quite a few medics who wouldn't give pain meds.


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## Smash (Nov 30, 2009)

*Oh dear...*

It's very sad to see that old saw of "analgesia masking symptoms" being trotted out by a Dr who should know better. 

This fallacy became popular in the 1920s following the publication of a boom on surgery written by a certain Mr Cope. Cope had no evidence for his statement beyond his own ideas, however this nonsense became very popular over the years. 

It has now been demonstrated as patently false following a number of studies (LoVecchio comes to mind, but I cant think of the others). In fact as has been alluded too, removing the affective aspect of pain (the distress) actually makes it easier to assess patients as they are able to better describe symptoms. Add to this the availability of FAST, CT, MRI and all the other wonders of modern technology, and it becomes clear that there is absolutely no need to leave a patient suffering.

You treated the patient appropriately, humanely and within the scope of your practice.  You have nothing to answer to, so stick to your guns and keep acting in the best interests of your patient.


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## redcrossemt (Nov 30, 2009)

Found a good literature review on the subject for those interested:

"Effect on diagnostic efficiency of analgesia for undifferentiated abdominal pain"; Thomas and Silen; British Journal of Surgery, Volume 90, Issue 1 (p 5-9).


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## Akulahawk (Nov 30, 2009)

Something that can be borrowed from the sports field is the idea of a tolerable level of pain. Achieving that can take some considerable care in titrating meds. What this achieves is you not blotting out the patient's sensation of pain nor does it just simply "take the edge off". On the pain scale, you're shooting for somewhere between a 1 and 3... For abdominal pain, the patient is still able to localize pain, and probably can localize it much better upon palpation. Snow them, and good luck finding out even IF they're having sympoms... provide no analgesia and they could feel pain no matter what you do. 

It also allows the patient to set their own level of tolerable pain. For some, no pain is tolerable. For others, they can tolerate what might be considered great pain. It's very individualized. 

Take the pain down to a tolerable level, do the exam, and _then_ blot the pain out.

That philosophy was one I learned prior to getting into Paramedicine and one reinforced during my clinicals. 

My impression is that prehospital pain management is still lacking... but it's a far sight better than it was. I, and I'm sure others, recall a time when NO pain management was available in the field outside the setting of MI.


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## ah2388 (Nov 30, 2009)

the service i ride with carries morphine and fentanyl, we have been instructed to titrate the meds(w fentanyl being preferred by most) until the pt pain is 0...not 1...not 2....0


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## zmedic (Nov 30, 2009)

It's always a good idea to keep in mind who is chewing you out. At some level 1 trauma centers they are training residents, including residents from fields other than EM (IM, ortho etc). So sometimes the "docs" you are getting yelled at don't know a ton about EM. On the other hand if you are getting chewed out by the chair of the department/experienced attending I'd really think about what they said and talk it over with your medical director to make sure the protocols are clear. If you are following protocols and the ED doc is chewing you out that's when it's time for the docs to fight it out.


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## redcrossemt (Nov 30, 2009)

zmedic said:


> It's always a good idea to keep in mind who is chewing you out. At some level 1 trauma centers they are training residents, including residents from fields other than EM (IM, ortho etc). So sometimes the "docs" you are getting yelled at don't know a ton about EM. On the other hand if you are getting chewed out by the chair of the department/experienced attending I'd really think about what they said and talk it over with your medical director to make sure the protocols are clear. If you are following protocols and the ED doc is chewing you out that's when it's time for the docs to fight it out.



After this incident, I spoke with a PA-C who works full-time in EM as well as the physician director of the ED. Both sided with me, and both also brought up that the literature supports pain management for these patients. They also both noted that it was within my protocols to provide such.


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## rhan101277 (Dec 1, 2009)

redcrossemt said:


> After this incident, I spoke with a PA-C who works full-time in EM as well as the physician director of the ED. Both sided with me, and both also brought up that the literature supports pain management for these patients. They also both noted that it was within my protocols to provide such.



I wouldn't feel bad about it at all.  Some people have personal issues and take it out on whomever.  One of the advantages of pre-hospital care is the ability to stop pain or mitigate it.  If they are in pain and you deem it necessary, it is your job to provide the best care, which includes pain management.  Some people are just grumpy people.


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## jason152318 (Dec 5, 2009)

This seems to be a common problem in the EMS system I work in as well. But as said by others, the hospitals assessment shouldn't be ruined by pain management pre-hospital. There are other tests and procedures that they will eventually have to do to come up with a final diognosis anyway, and in most cases the pt's arent pain free upon hospital arrival. So bringing a pt from a 10-10 pain down to a 3-10 pain isnt going to ruin the assessment for example, and eventually the meds will stop doing there job. As long as you are following protocol, that is really what matters.


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## sdadam (Dec 5, 2009)

Here is some research supporting what most everyone has said.

Pain management has no effect on the accuracy of diagnosis. And withholding it is arcane and poor medicine.

http://www.ahrq.gov/CLINIC/ptsafety/chap37a.htm

In fact according to one study (and this is just one study, I realize we should never change practice based off a single study, regardless of the results) ended up having a significantly higher rate of miss diagnosis in the PT who didn't receive pain control. 



> Attard et al6 found no difference in localization of physical signs, and no difference in the surgeon's diagnostic confidence or management decision (to operate or to observe) between the 2 groups (opioids vs. placebo). The decision to operate or to observe was incorrect in 2 patients in the opioid group (4%) and in 9 patients in the placebo group (18%).



The above link reviews five different studies, all of which had similar outcomes.

When it comes to the way the Dr. treated you, i would respectfully disagree with her, if she turned her back on me I would kick her in the balls.

(kidding, just so were all clear I wouldn't actually kick a Dr. in her non-existant balls)

Adam


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## mycrofft (Dec 5, 2009)

*Human factor at work.*

There are three times a doctor will take you aside...to save you embarassment, to spare the patient or family extra anxiety (or grounds to sue), or to get you away from others and whittle at you, maybe in a fashion her/his peers are fed up with. If the family isn't there, you decide if you are being tutored, or cut out of the herd for a little torment. Even if you are being chewed on a little sadistically, there may be a point to learn if not agree with or adopt. 
Me, I cut in, establish if I'm being Sadimized (run over by a Sadist), establish if I'm truly in trouble or not, then either walk away or stop and talk for a bit.


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## EricCSU (Jan 9, 2010)

This very topic was the topic of a previous research paper that I wrote and consequently turned into a presentation.  I would be happy to email it to you if you provide your email address in a PM.

As far as your question, here are my thoughts:

Patient assessment is actually much easier following appropriate analgesia (this is supported by mounds of research as well as anecdotally).  What was previously diffuse abdominal pain with a patient writhing is not tenderness concentrated to a very defined area.

Effective analgesia is one of the few times we can make an actual difference in someone's life.  Pain is not just a nuisance, it is a significant problem which must be treated. 

Eric

P.S. Short of posting the entire paper in this forum, here are my references:

[1] Position Paper: Prehospital Pain Management.  National Association of EMS Physicians. Prehospital Emergency Care.  October-December 2003.  482-488.
[2] Why Don’t We Do a Better Job of Treating Pain?.  Bryan Bledsoe, DO.  http://www.bryanbledsoe.com/pdf/handouts/PowerPoint/Pain Management.ppt#256,1,Why Don’t We Do a Better Job of Treating Pain?
[3] Pain Management in the Prehospital Environment.  McManus MD, Sallee MD.  Emergency Medical Clinics of North America.  2005.  415-431.
[4] Prehospital Pain Management: Current Status and Future Direction.  Hennes MD, Kim MD.  Clinical Pediatric Emergency Medicine.  2006. 7:25-30.
[5] Pain Medication Administration in Pediatric Trauma Patients with Long Bone Fractures Before Emergency Department Arrival.  Mader MD, Letourneau MD.  Annals of Emergency Medicine. October 2004. 44.
[6] Inadequate Analgesia in Emergency Medicine.  Rupp MD, Delaney MD.  Annals of Emergency Medicine.  April 2004. 494-503.
[7] Refusal of Base Station Physicians to Authorize Narcotic Analgesia.  Gabbay MD, ****inson MD.  Prehospital Emergency Care.   July-September 2001.  293-295.
[8] Simplyifying Prehospital Analgesia.  Bledsoe DO, Braude MD, Dailey MD, Myers DO, Richards MD, Wesley MD.  Journal of Emergency Medical Services.  July 2005.  57-59.
[9] Changing Attitudes About Pain and Pain Control in Emergency Medicine.  Fosnocht MD, Swanson MD, Barton MD.  Emergency Medicine Clinics of North America.  2005.  297-306.
[10] The Epidemiology of Pain in the Prehospital Setting.  McLean MD, Maio MD, Domeier MD.  Prehospital Emergency Care. October-December 2002. 401-405.
[11] Few Emergency Medical Services Patients with Lower-extremity Fractures Receive Prehospital Analgesia.  McEachin BSN, McDermott EMT-P, Swor DO.  Prehospital Emergency Care.  October-December 2002.  406-410.


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## COWSskateGOOD (Jan 14, 2010)

I treat my patients how I would treat my family member, or by the golden rule : Treat Others as how you wish to be treated.... What would I want in that scenario if it were me in pain.

Something I have learned: Always err on the side of the patient...


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## firetender (Jan 14, 2010)

I just want to say I think this is a really potent and exemplary thread that really, REALLY informs the readers and gets them to think as well.

BRAVO!

...and, then, putting myself in the head of today's typical physician, how about this simple, malpractice-related formula:

_Abdominal pain = Surgery = Consent. _
------------------(divided by) ----------- _ *...............= LIABILITY FOR*_
_Meds prior to signing =  questionable consent_ _................_*POOR OUTCOME*


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## rhan101277 (Jan 15, 2010)

I'm still learning, but most of the trauma patients that come in don't have pain meds on board.  I know most are not stable, but I think the ones that have stable blood pressure and has been trending stable should get at least 4mg morphine.

Like this one guy that came in with bilateral gunshot wounds to the legs.  Stable patient but in pain.  We are there to treat pain, but sometimes its a double edged sword because you gotta worry about BP.


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## AnthonyM83 (Jan 15, 2010)

Any chance it was the part about being able to join the committee that decides protocols? I honestly have no idea how it was said, but usually when discussions get to that point, one has moved away from the actual topic...


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## redcrossemt (Jan 15, 2010)

AnthonyM83 said:


> Any chance it was the part about being able to join the committee that decides protocols? I honestly have no idea how it was said, but usually when discussions get to that point, one has moved away from the actual topic...



It's an interesting thought. However, I only got to the point of saying that when the physician said my protocols were "poorly written" and shouldn't include pain management for abdominal pain.


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## grich242 (Jan 15, 2010)

redcrossemt said:


> It's an interesting thought. However, I only got to the point of saying that when the physician said my protocols were "poorly written" and shouldn't include pain management for abdominal pain.


 
   Remember that the protocols we work under are relitavely new in the sense that only 6 years ago we were usualy unable to get orders for anything with many doc's in the system stating on more than on occasion that we would never get orders for ANY reason... most of our tretments were post radio... that being said the protocols and attitudes of the docs at area er's have come a long way.


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## Veneficus (Jan 15, 2010)

We are taught in school pain management doesn't affect the ability to dx a surgical abdomen and to aggresively manage pain. 

If you really wanted to be a smart A** you could ask how pain control intereferes with a CT scan, since in the US nobody I have heard of is going to rule out anything significant without a scan.


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## redcrossemt (Jan 15, 2010)

grich242 said:


> Remember that the protocols we work under are relitavely new in the sense that only 6 years ago we were usualy unable to get orders for anything with many doc's in the system stating on more than on occasion that we would never get orders for ANY reason... most of our tretments were post radio... that being said the protocols and attitudes of the docs at area er's have come a long way.



My point is that we need to progress further! It's a sad day in my book when a physician is withholding pain medication for abdominal pain, when the paramedics know the research is there to support it and have the protocols to do it.


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## redcrossemt (Jan 15, 2010)

Veneficus said:


> We are taught in school pain management doesn't affect the ability to dx a surgical abdomen and to aggresively manage pain.
> 
> If you really wanted to be a smart A** you could ask how pain control intereferes with a CT scan, since in the US nobody I have heard of is going to rule out anything significant without a scan.



Thank you.

Oh, I understand why we shouldn't manage pain now! Obviously opiates block x-ray radiation and prevent good imaging studies!


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## JPINFV (Jan 16, 2010)

redcrossemt said:


> Thank you.
> 
> Oh, I understand why we shouldn't manage pain now! Obviously opiates block x-ray radiation and prevent good imaging studies!



I believe he was being sarcastic with that comment. As in ask the attending how exactly opiates affects cat scans.


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## redcrossemt (Jan 16, 2010)

JPINFV said:


> I believe he was being sarcastic with that comment. As in ask the attending how exactly opiates affects cat scans.



LOL and I was trying to be sarcastic back. Maybe I should've winked.


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## JPINFV (Jan 16, 2010)

::whistles::


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## Aidey (Jan 16, 2010)

So often now ambulances have one, maybe two methods of pain control. Nearly always an opiate. Giving certain abdominal issues certain opiates can make them worse (namely bowel obstructions). It isn't always about diagnosing the problem, but making sure the pain control isn't going to make the problem worse. It would be nice if we were able to have more options so that we weren't doing this "one size fits all" pain control. 

I think if we were able to do that we could have more progressive protocols about treating things like abdominal pain, back pain, and severe headaches. I would also like to see more protocols allowing for a skeletal muscle relaxants in dislocation cases.


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## spikestac211 (Jan 16, 2010)

OP: So what was it, kidney stone?


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## BLSBoy (Jan 16, 2010)

rhan101277 said:


> We are there to treat pain, but sometimes its a double edged sword because you gotta worry about BP.



With Fent, it doesn't have as much of a response on the BP that Morphine would.


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## FLEMTP (Jan 16, 2010)

I think overall, fentanyl is a better medication for pain management, prehospital any how.. and it is very versatile in its uses.. since many agencies also use it for either pre or post medication/analgesia for drug assisted intubation

I do think that morphine should still be carried as an alternative in the case of allergies, or prolonged transports, or in situations where a slight decrease in blood pressure would be to the patient's benefit. 

Also, im not sure, only because I havent personally seen any studies, but does phenergan potentiate fentanyl like it does morphine? Sometimes I prefer to give a patient morphine with phenergan together, ie: abdominal pain with nausea/vomiting... or with a nauseaed/vomiting chest pain/cardiac patient.


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## fire_911medic (Jan 16, 2010)

*Pain Management*

Here we are very fortunate regarding docs supporting us with pain management, and I have seen medics disciplined by the docs for not giving pain meds due to some of the reasons stated (short trip, didn't think they needed them, etc).  It may be a short trip, but many times, especially in a busy ER or if seriously injured, many things will take precedence over giving pain meds and the patient will sit on a backboard or in a stretcher for quite a while uncomfortable.  Be proactive with pain management.  If a patient tells you they are in pain, it is your responsibility to attempt to alleviate that pain.  I am very considerate with pain meds as I know what it's like to be in the patient's shoes and sitting around in extreme pain while you're waiting for someone to get to you, so I think that forms my opinion and shapes the way I practice a bit more than someone who's not been in that position.  I've had docs fuss at me a few times, but rarely.  My response always is the same - my patient complained of pain, and it's not my job to determine whether that pain is real or not - they qualified and quantified their pain, and I worked within my protocols to relieve that pain.  I've never had them question that response.


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## grich242 (Jan 16, 2010)

redcrossemt said:


> My point is that we need to progress further! It's a sad day in my book when a physician is withholding pain medication for abdominal pain, when the paramedics know the research is there to support it and have the protocols to do it.


 Sorry I got cut off and didn't finish I also wanted to add that that is not the attitude shared in large by the md's at the 4 er's that I work out of. Its out dated and the protocols were changed in many ways to allow us the freedom to practice those skills like pain management as we are trained and licensed to do. We continue to push to make improvements to provide better care and system wide improvements. It helps when medics provide good competent care and arguments like hers will fall on deaf ears, as far as med control goes. so ignore her and continue to provide care.


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## Aidey (Jan 16, 2010)

FLEMTP said:


> I think overall, fentanyl is a better medication for pain management, prehospital any how.. and it is very versatile in its uses.. since many agencies also use it for either pre or post medication/analgesia for drug assisted intubation



Myself and most of the other medics I work with are not fans of fentanyl. For some things it works well, but for orthopedic injuries I've never had a good response to it, even giving large doses.


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## reaper (Jan 17, 2010)

I have seen the exact opposite. On Ortho injuries, Fentanyl is rapid onset and much better pain relief then Morphine. These are the results I have seen. Most pt's have almost full relief with 50mcg, some need 100 mcg.


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## Aidey (Jan 17, 2010)

Interesting. I've had to max out people to make a significant dent in their pain levels.

This is an example of what seems to happen. 

Person with pain 8/10 gets 25mcg, pain goes down to a 7. Another 25mcg. Nothing. Another 25mcg. Nothing. Another 25mcg. Pain drops to a 5/10.


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## reaper (Jan 17, 2010)

What was the time intervals between doses? Fentanyl has a short half life. So if you were 10 minutes between doses, they were only getting 25 mcg at a time. That would not affect pain greatly. I always start at 50mcg and sometimes start at 100mcg, depending on the pt.


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## SammyGirlMedic (Jan 17, 2010)

redcrossemt said:


> I'm not questioning you, but have you ever used fentanyl before? I know they say that fentanyl is 100 times more powerful than morphine, but I've never seen 100mcg of fentanyl compare to the analgesia or sedation properties of 10mg of morphine. In fact, our region's maximum dose increased from 2mcg/kg to 3mcg/kg because we weren't always getting adequate analgesia from 2mcg/kg doses, and the drug was proven to be safe, effective, and well-utilized among paramedics in our region.
> 
> Patient in said scenario weighed 60kg. She initially got 60mcg, and got another 30 mcg when her pain was not relieved by the first dose after 10 minutes or so. She tolerated it well and wasn't "wasted" or unable to participate in a continued exam or treatment.



Medication affects everyone differently. I had a 50kg patient to whom I gave 50mcg of Fentanyl. It did nothing. I gave her another 50 mcg and it "took the edge off" but she actually seemed rather ticked off like she was thinking to herself, "oh thanks for nothing for my tib/fib fx!"
In another instance, a fellow paramedic, who weighs a good 140kg was completely snowed from the 150mcg he got in the ED for a headache he had while having a stroke.

Plus everyone's personal perception of pain is different. Some people are wimps and others can handle it! ;-)


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## usalsfyre (Jan 17, 2010)

My experince with Fentanyl is that it is better to front load with a large dose (1-2 mcg/kg) and follow up with smaller maintnance doses for breakthrough pain at 10-15min intervals. It's not a med that I've seen work well in 25-50mcg doses.


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## SammyGirlMedic (Jan 17, 2010)

usalsfyre said:


> My experince with Fentanyl is that it is better to front load with a large dose (1-2 mcg/kg) and follow up with smaller maintnance doses for breakthrough pain at 10-15min intervals. It's not a med that I've seen work well in 25-50mcg doses.



Makes sense. 
My little old lady weighing 50kg only got 50mcg because our dose is only 1mcg/kg.. granted I can call in for more, but they won't let me front load with the 2mcg/kg.. they'll tell me to give more only if I tried the 1mcg/kg first. Crappy.


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## Veneficus (Jan 17, 2010)

SammyGirlMedic said:


> Makes sense.
> My little old lady weighing 50kg only got 50mcg because our dose is only 1mcg/kg.. granted I can call in for more, but they won't let me front load with the 2mcg/kg.. they'll tell me to give more only if I tried the 1mcg/kg first. Crappy.



Is your med control out of St. Es?


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## Aidey (Jan 17, 2010)

reaper said:


> What was the time intervals between doses? Fentanyl has a short half life. So if you were 10 minutes between doses, they were only getting 25 mcg at a time. That would not affect pain greatly. I always start at 50mcg and sometimes start at 100mcg, depending on the pt.



My example was what has happened on several calls, so I couldn't tell you exactly what the dosing interval was. I know that I try and keep it short because of the 1/2 life, but like I said, I don't remember specifics. 




usalsfyre said:


> My experince with Fentanyl is that it is better to front load with a large dose (1-2 mcg/kg) and follow up with smaller maintnance doses for breakthrough pain at 10-15min intervals. It's not a med that I've seen work well in 25-50mcg doses.



Unfortunately we can't do this. A Fire-medic gave a tiny old woman a large dose up front and when she developed respiratory depression he promptly forgot that we carry narcan....

I don't remember if she died or not, but the situation wasn't pretty. We (both the fire medics and the private service medics) are restricted to pretty low doses. No more than .5mcg/kg tops.


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## usalsfyre (Jan 17, 2010)

Aidey said:


> No more than .5mcg/kg tops.



That's a problem. I very rarely gave less than 100mcgs a first dose, with 50-100mcg follow up doses.


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## Aidey (Jan 17, 2010)

Yeah.....the whole situation is stupid. Everyone was punished because one fire medic lost his head when he overdosed the patient. There were so many other things they could have done first, such as remedial training, but they jumped straight to rewriting the protocols. They actually prefer we start with .25mcg/kg, but we can give a max of .5mcg/kg at once.


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## zmedic (Jan 18, 2010)

Our dose was 1-2mcg/kg. Most people drew up 1mcg/kg and saw the effect, then pushed another dose if needed.


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## SammyGirlMedic (Jan 18, 2010)

Veneficus said:


> Is your med control out of St. Es?



Nope


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## rhan101277 (Jun 9, 2011)

I know I am bringing up an old thread, but I gave pain medication the other day to a pt who had C/C of fell three days ago. Pt. states re-injured right ankle doing housework today, right little toe is rotated.  It is tender to the touch and swollen.  Pt reports pain 8/10; also has a hx of chronic back pain.  Pt reports only given 3 days of pain meds and it now out and couldn't sleep last night due to pain  These chronic pain patients may/may not not present with HTN or tachycardic, tachypneic.

Anyhow I get to ER and I am told by physician that it was "a little over the top" to start an IV and give morphine.  Turns out pt had been prescribed plenty of pain meds and was probably drug seeking.  I refuse to get into the mind set that every patient that I encounter who is in pain can just tough it out till the hospital, since they are probably lying to me anyway.  I am not there to pass judgment, they initiated EMS system so I am there to help.

Maybe I should bring one of those magic 8 balls and use it after I ask each question to determine whether my pt is lying or what not.

Physician ordered IV taken out and pt sent to waiting room in wheelchair.  Physician was not irate or anything but still, I am going to continue to follow protocols and if pain management is warranted I am going to do so.


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## jwk (Jun 9, 2011)

rhan101277 said:


> I know I am bringing up an old thread, but I gave pain medication the other day to a pt who had C/C of fell three days ago. Pt. states re-injured right ankle doing housework today, right little toe is rotated.  It is tender to the touch and swollen.  Pt reports pain 8/10; also has a hx of chronic back pain.  Pt reports only given 3 days of pain meds and it now out and couldn't sleep last night due to pain  These chronic pain patients may/may not not present with HTN or tachycardic, tachypneic.
> 
> Anyhow I get to ER and I am told by physician that it was "a little over the top" to start an IV and give morphine.  Turns out pt had been prescribed plenty of pain meds and was probably drug seeking.  I refuse to get into the mind set that every patient that I encounter who is in pain can just tough it out till the hospital, since they are probably lying to me anyway.  I am not there to pass judgment, they initiated EMS system so I am there to help.
> 
> ...



Something is missing here.  You said they had a 3-day supply of pain meds - for what, from where?  That sounds like an ER prescription, and the patient was supposed to follow up with their PMD or perhaps orthopod after their initial injury.  It sounds like they didn't do that.


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## usalsfyre (Jun 9, 2011)

rhan101277 said:


> Anyhow I get to ER and I am told by physician that it was "a little over the top" to start an IV and give morphine.


Actually, he's really probably right. EMS suffers from dearth of pain management options. It's either nothing, or killing a flea with a shotgun (IV narcs). If I ruled the world, you'd see varried options for EMS, methoxflurane or entonox (both not approved for US use), PO and IV NSAIDS and APAP, PO narcs, IV narcs mixed with benzos and ketamine. 



rhan101277 said:


> Turns out pt had been prescribed plenty of pain meds and was probably drug seeking.  I refuse to get into the mind set that every patient that I encounter who is in pain can just tough it out till the hospital, since they are probably lying to me anyway.  I am not there to pass judgment, they initiated EMS system so I am there to help.
> 
> Maybe I should bring one of those magic 8 balls and use it after I ask each question to determine whether my pt is lying or what not.


The correct attitude, and like I said, unfortunately we've got to continue to kill fleas with shotguns. 



rhan101277 said:


> Physician ordered IV taken out and pt sent to waiting room in wheelchair.  Physician was not irate or anything but still, I am going to continue to follow protocols and if pain management is warranted I am going to do so.


Fortunately the physician was willing to do this. Not an inapproprite way of opperating, but one many hospitals are uncomfortable with due to liability concerns. Narcotics are not nearly as dangerous as their made out to be in emergency medicine, but they're still seen as the boogey man by many.


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## johnrsemt (Jun 9, 2011)

It isn't EMS's job to decide if the patient is a drug seeker or not:  some ED's give scripts for 2-3 days of pain meds with orders to patient to follow up with Ortho doc or family doc; and they can't get into see the doc for 5-10 days: esp if ED was Friday  and doc isn't open til monday to even call.
  So when we get called back to house on Sunday evening because they are out of meds and they are in pain:  I give them pain meds to make them comfortable.


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## rhan101277 (Jun 9, 2011)

I think the doc was frustrated because the pt did not follow up.  Thanks for the replies.  If we were allowed to give PO meds for pain (Lortab etc.) I would have done that for this particular instance.


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## bigbaldguy (Jun 9, 2011)

Are there any EMS systems (international) that allow EMS to prescribe narcotic PO meds to patients.

Sorry I should clarify that. By prescribe I mean give the patient say a 3 day supply of meds. I know in some systems pre hospital folks can do something similar with antibiotics and such.


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## rhan101277 (Jun 9, 2011)

Wake County, NC. allows PO meds for pain <6/10.  No scripts though.


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## jwk (Jun 10, 2011)

bigbaldguy said:


> Are there any EMS systems (international) that allow EMS to prescribe narcotic PO meds to patients.
> 
> Sorry I should clarify that. By prescribe I mean give the patient say a 3 day supply of meds. I know in some systems pre hospital folks can do something similar with antibiotics and such.



Hmmm, that doesn't sound right, narcotics, antibiotics, or otherwise.  That would be called dispensing, and in most states that means pharmacist-only with a few exceptions.


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## WelshMedic (Jun 14, 2011)

MrBrown said:


> I agree that prehospital analgesia is very important and that patients need to recieve adequate analgesia.
> 
> That said, lets say this patient was 50kg (50mcg of fentanyl at 1mcg/kg) is equivalent to 5mg of morphine.  If she was 50g at this guy'd dose of 1.5mcg/kg that's like 7.5mg of morphine.
> 
> ...



I think you make a good point here. In a healthy 26yr old then 1.5mcg/kg shouldn't be a huge dose, but it also depends on their build and PMH. I would start at 1mcg/kg and titrate up from there.

Carl


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## FFEMT427 (Sep 30, 2011)

*Proper use of MS*



MrBrown said:


> I agree that prehospital analgesia is very important and that patients need to recieve adequate analgesia.
> 
> That said, lets say this patient was 50kg (50mcg of fentanyl at 1mcg/kg) is equivalent to 5mg of morphine.  If she was 50g at this guy'd dose of 1.5mcg/kg that's like 7.5mg of morphine.
> 
> ...



Do you realize that a standard low end dose of MS is 0.1 mg/kg and therefor if you start out at 2mg for a 50kg pt you are giving less than half of a suggested low end dose. 
Its not all our fault in the field we are fighting through years of dogma that treating pain in the field will somehow slow down docs in the ED. That is a falsehood (Well if you have sharp docs in your ED).
Think about the thing that we can help our pt.'s out with the most.
What percentage of pt.'s do we put crics in? How many do we cardiovert? But how many pt.'s have you had that have pain. Therefor it is an area where we can cause alot of good.
1.5 mcg/kg of fent Bravo
There is an equation that I did not make up but will pass on from now till the end of my career it is  severe pain + 2mg Morphine = servere pain.


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## KellyBracket (Oct 3, 2011)

I would just ask that the OP make ever-so-slight an adjustment to the title. Since it was one physician who made the comment, perhaps the title shoul be something more like "This _One_ Physician's Impression..."  

A few of us generally like the idea of aggressive prehospital analgesia. Frankly, I wouldn't mind seeing a few more"inappropriate" morphine doses given in the field, since it would probably mean that a heck of a lot more "appropriate" doses were also being given!


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## daj72 (Oct 3, 2011)

Linuss said:


> First point:  Tough luck to the physician.  You're working under your med directors license, not hers.  If she doesn't like how something is done and it's in accordance to what your MD accepts, tough noogies, it's not her call.  Doesn't want an IV?  Start one if you deem necessary.  If she keeps complaining, ask her if she's willing to be co-named on the lawsuit for not providing an IV to someone who needed it.
> 
> 
> 
> As far as pain control for abd pain, I've spoken to a few Docs and PAs on the matter and they are all pretty much in agreement:  Pain meds should not make or break their diagnosis, and should not slow down their assessment.  If you deem your pt needs pain control, then do pain control.



What this dude is saying


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## Handsome Robb (Oct 3, 2011)

KellyBracket said:


> A few of us generally like the idea of aggressive prehospital analgesia.



You can include me in that statement, along with my medical director.


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## jjesusfreak01 (Oct 8, 2011)

rhan101277 said:


> Wake County, NC. allows PO meds for pain <6/10.  No scripts though.



As a WakeEMS employee, i'll mention that Tylenol is given only very rarely, and generally for patients with very minor injuries. Severe pain from any condition for which surgery will not be required will get Toradol, and if there is any chance of surgery in the pts future, Morphine or Fentanyl.


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## KellyBracket (Oct 9, 2011)

Interesting decision tree for analgesics. I'm not sure that EMS should have the burden of guessing whether surgery will be indicated before administering morphine. Is this the protocol, or your experience?



jjesusfreak01 said:


> As a WakeEMS employee, i'll mention that Tylenol is given only very rarely, and generally for patients with very minor injuries. Severe pain from any condition for which surgery will not be required will get Toradol, and if there is any chance of surgery in the pts future, Morphine or Fentanyl.


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## Fish (Oct 9, 2011)

redcrossemt said:


> Patient Summary: 26 y/o female with worsening left flank pain over the past 3 days. It has been a 2-3 out of 10, just kind of achy; but this morning is a "20" out of 10, woke patient out of her sleep, and she couldn't get back to sleep because of the pain. Patient was tachycardic, tachypneic, wincing, and generally appeared to be in distress. Interventions included 1.5 mcg/kg of fentanyl IV. Our transport time was about 8 minutes.
> 
> After patient care had been transferred and report given to nursing staff, the ER physician took me aside and asked me why I had given fentanyl to this particular patient. I reiterated the story above, emphasizing that the patient said she was in severe pain, and appeared to me to be in distress. I also reiterated our pain management protocol, and that the pre-hospital standard of care now includes pain relief. The physician seemed very upset with this, stating that it impaired her assessment of the patient, and that the "ride over here was only 8 minutes" and the patient could wait for pain medicine. She even said that us giving pain medicine makes their "2mg of morphine seem not so great" to the patient.
> 
> ...



If your patients in Pain, then relieve the pain(It is your job) If they need an IV start an IV(its your job) If that MD has a problem with this, well then I think your Medical Director should be made aware so that they can have a chat.


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## Shishkabob (Oct 9, 2011)

There's few things I can argue with a physician on where 8 years vs 2 years education doesn't matter... analgesia is one of them.   :lol:


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## jjesusfreak01 (Oct 9, 2011)

KellyBracket said:


> Interesting decision tree for analgesics. I'm not sure that EMS should have the burden of guessing whether surgery will be indicated before administering morphine. Is this the protocol, or your experience?



Experience. We don't use Toradol very often at all. Its usually, "suck it up" or Morphine...


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## redcrossemt (Oct 13, 2011)

spikestac211 said:


> OP: So what was it, kidney stone?



Sorry for the delay. I've been away from the forum, occupied with other things.

Indeed it was a kidney stone.


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## redcrossemt (Oct 13, 2011)

Linuss said:


> There's few things I can argue with a physician on where 8 years vs 2 years education doesn't matter... analgesia is one of them.   :lol:



True story. Sad to see that this post was revived! Things are in general better in our system now, a year later, with fairly widespread acceptance of prehospital pain management.

As far as dosing, our new protocols allow 1 mcg/kg fentanyl up to a total of 3 mcg/kg, and/or morphine 0.05 mcg/kg up to 20 mg. We also have midazolam available now, which we have used (post-radio) for painful procedures with great success.


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## Bryan (Nov 19, 2011)

Hmmmm thanks for sharing this i really like ur post it was quite helpful quite interesting i got so many new things in this post u really have the knowledge thanks.........


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## DV_EMT (Nov 19, 2011)

aslo, you have to consider a patients tolerance for pain as well as body weight...

I.E.... I have an OK pain tolerance, but for the most part, If I require pain meds from an MD, I usually request Vicodin with the standard 1-2 Q4-6 prn Pain. I usually need 2 of them to even feel any relief, and its because I can handle my meds (like my drinks) with ease. One vicodin does nothing to my pain level.

Personally, If i know someone isn't faking it and is in True Pain and shows signs/symptoms such as tachycardia/diaphorsis etc... why not help them out with something to make them more comfortable. (this doesnt include migrane and other "petty" problems).


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## Cawolf86 (Nov 19, 2011)

Are you guys pretty comfortable with treating pain in infants? I had an 11 month old last night with approx 10% BSA 1st degree and approx 2% 2nd degree burns - from scalding. Infant was in obvious distress but mom wasn't comfortable with her child getting MS. Kid was 11kg - I was going to give our starting dose of 0.1mg/kg IM - 1.1mg IM. By the time I was getting mom to understand we were at the hospital. Doctor ended up giving the same MS dose. Thoughts on analgesia in those too young or old to express their pain verbally? Or speaking to parents/caregivers?


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## Smash (Nov 19, 2011)

DV_EMT said:


> why not help them out with something to make them more comfortable. (this doesnt include migrane and other "petty" problems).



I really hope that I have just misunderstood your post, and that you haven't just referred to migraine as a "petty problem"


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## DV_EMT (Nov 19, 2011)

Smash said:


> I really hope that I have just misunderstood your post, and that you haven't just referred to migraine as a "petty problem"



Yeah... I was referring to other minor dumb injuries as "petty" not the migranes. Subject-verb agreement error on my part


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## systemet (Nov 19, 2011)

Cawolf86 said:


> Are you guys pretty comfortable with treating pain in infants? I had an 11 month old last night with approx 10% BSA 1st degree and approx 2% 2nd degree burns - from scalding. Infant was in obvious distress but mom wasn't comfortable with her child getting MS. Kid was 11kg - I was going to give our starting dose of 0.1mg/kg IM - 1.1mg IM. By the time I was getting mom to understand we were at the hospital. Doctor ended up giving the same MS dose. Thoughts on analgesia in those too young or old to express their pain verbally? Or speaking to parents/caregivers?



I think you're right to want to pain control this child.  It's a shame the mother wouldn't agree.  I wasn't there, but it doesn't sound like it's your fault she refused.

I don't know how your system is set up, or if there was any suspicion that this was an act of abuse or that the child might have other more serious injuries.  I would prefer to start an IV, or give IM pain medication prior to transport, then give additional pain medication en route.  Based on the information provided, I wouldn't consider this a time-critical trauma patient.

Did the mother explain why she didn't want pain control?  It seems like a strange decision.


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## Cawolf86 (Nov 19, 2011)

systemet said:


> I think you're right to want to pain control this child.  It's a shame the mother wouldn't agree.  I wasn't there, but it doesn't sound like it's your fault she refused.
> 
> I don't know how your system is set up, or if there was any suspicion that this was an act of abuse or that the child might have other more serious injuries.  I would prefer to start an IV, or give IM pain medication prior to transport, then give additional pain medication en route.  Based on the information provided, I wouldn't consider this a time-critical trauma patient.
> 
> Did the mother explain why she didn't want pain control?  It seems like a strange decision.



In my system a call for a child that young with a c/c of trauma, burns, hemorrhage, traumatic injury, etc - generates a PD response. They examined the scene and interviewed mother after I left. Physical assessment didn't reveal any other signs of trauma or neglect - old or new. Child was well nourished, living quarters were adequate, and she seemed consolable by mom. I documented it as I saw as how it allegedly occurred. We have the channels available to report child abuse - in this case I chose not to. Mother seemed worried about analgesia due to side effects and a slight language barrier. Transport time was 5 minutes and by the time she understood we were at the ED.


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## WTEngel (Nov 19, 2011)

I always get frustrated with parents who are reluctant to allow providers to administer pain meds to their child. I know they are typically genuinely concerned, but if this mother had scalding burns to 10% of her body, I garauntee she would want some pain meds.

I am extremely comfortable giving pain meds to kids, mostly because that's my area of expertise, but also because pain management is just as important in these patient as it is in adults.

I have had parents be reluctant to allow pain meds for their child before, but as a provider, it is my duty to provide relevant education on the issue, and project the confidence necessary to gain the parents trust. If I can't give them a valid reason other than "it's good for your kid" and I appear uncomfortable, of course the parent isnt going to trust me.

If I can explain to the parents how important it is to keep their child comfortable and minimize pain in order to allow me to best assess and care for them. 

Most of the time because I work peds critical care, parents have total trust. If they don't, we have to quickly earn that trust in order to get the parents on the same page with us, and facilitate family centered care. 

Parents can be educated about the benefit of a procedure and generally get over the mental obstacle they have of not wanting the procedure due to it causing discomfort to the child, or any concern they have about complications. The goal should be to take any and all emotion out of informed consent. Your interactions and attitude have everything to do with how the parents will deal with the stress of the situation.


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## Smash (Nov 19, 2011)

DV_EMT said:


> Yeah... I was referring to other minor dumb injuries as "petty" not the migranes. Subject-verb agreement error on my part



Phew!  

Pain relief in kids and elderly can be problematic, mostly because of communication issues, but sometimes because of attitudes or beliefs of care-givers, and sometimes unfortunately providers.  I've worked with people who refuse to cannulate children, unless they are in arrest, which is bizarre and more cruel than actually placing a line and giving pain relief.  

Intranasal fentanyl can be quite effective in children where you don't want to, or can't start a line.  I'm also fascinated by fentanyl lollipops, but I'm picking I won't get them on the truck any time soon - so much potential for abuse!

I always try to apply a common sense approach to my care and to explaining stuff to parents - does that look like it would hurt?  It gets pain relief!  Does that look like it would hurt you?  Then let your kid have pain relief!


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## Nervegas (Nov 19, 2011)

Smash said:


> Intranasal fentanyl can be quite effective in children where you don't want to, or can't start a line.  I'm also fascinated by fentanyl lollipops, but I'm picking I won't get them on the truck any time soon - so much potential for abuse!



Could always have one the the glass ampules crack weird and spray fentanyl everywhere, including the medics eye who tried to open it, ocular administration anyone?


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## Farmer2DO (Nov 20, 2011)

Smash said:


> I really hope that I have just misunderstood your post, and that you haven't just referred to migraine as a "petty problem"



While a migraine isn't a petty problem by any means (I get them myself), we are discovering in medicine that opiates for headaches without skull fractures or ICH are one of the worst things we can do.  Patients bounce back and end up needing large doses of narcotics.  Most physicians in my area refuse to give narcotics for migraines.


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## DV_EMT (Nov 20, 2011)

Farmer2DO said:


> While a migraine isn't a petty problem by any means (I get them myself), we are discovering in medicine that opiates for headaches without skull fractures or ICH are one of the worst things we can do.  Patients bounce back and end up needing large doses of narcotics.  Most physicians in my area refuse to give narcotics for migraines.



Seems like anti imflamatories would be a better route?


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## Smash (Nov 20, 2011)

Farmer2DO said:


> While a migraine isn't a petty problem by any means (I get them myself), we are discovering in medicine that opiates for headaches without skull fractures or ICH are one of the worst things we can do.  Patients bounce back and end up needing large doses of narcotics.  Most physicians in my area refuse to give narcotics for migraines.



Indeed, which is why we give prochlorperasine, metoclopramide, lidocaine, steroids depending on the situation.  Which of course does not detract from the need for pain relief, but rather highlights the lack of options that most systems have for managing pain.


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