# Morphine Administration



## rhan101277 (Dec 18, 2010)

I know many providers are stand-offish about giving pain meds.  I think relieving pain is something good.  Many folks at my job are proponents of it.  Anyhow our protocols say that pain management is indicated on any isolated extremity injury with pain scale greater than 5 out of 10.

I had a guy with a broke/dislocated finger.  I have had a jammed thumb before and the pain was bad.  Just because it is something small doesn't mean that it is ok to let them ride in pain.  I know it was strange for them to call 911 for this but still they are paying and they might as well get some relief.  No tachycardia, but grimacing and deformity is easily noticeable.

What do you all think?


----------



## Shishkabob (Dec 18, 2010)

"Would you like something for the pain?"


If yes, give it.  If slapped on the hand for it not being a 5, then everyone in pain becomes a 5.


----------



## usalsfyre (Dec 18, 2010)

The most common med I push is fentanyl, what do you think?


----------



## medicRob (Dec 18, 2010)

I don't withhold pain meds. If I believe my patient is in pain or my patient tells me they are in pain,  I will administer them. I will leave it to the ER docs to play the little, "Who's a drug seeker game" .. I personally try not to pass such judgements.


----------



## abckidsmom (Dec 18, 2010)

I give the meds.  Even if they are drug seekers, it's a pathetic little high.


----------



## TransportJockey (Dec 18, 2010)

medicRob said:


> I don't withhold pain meds. If I believe my patient is in pain or my patient tells me they are in pain,  I will administer them. I will leave it to the ER docs to play the little, "Who's a drug seeker game" .. I personally try not to pass such judgements.



This. If they tell me they're in pain, they get something (in the areas I can give narcs anyway [ie NM])


----------



## emtpche (Dec 18, 2010)

I agree, if in pain give meds. See to many  medics withholding under the misconception of creating drug seekers.  Would like to see Fentanyl on our rigs.  Morphine does little for pain management.


----------



## usalsfyre (Dec 18, 2010)

emtpche said:


> Morphine does little for pain management.



Morphine is a very good adjunct to pain management, dosed appropritely. 2mgs isn't approprite.


----------



## emtpche (Dec 18, 2010)

While MS works for some folks I find that most require a higher dosage to bring the pain down. Also Fentanyl has less side effects than MS esepcially in  ACS.


----------



## Aidey (Dec 18, 2010)

I personally have found the opposite. Morphine has more side effects, but works better. Occasionally Fent works well in a patient, but more often than not it doesn't do much. 

I have a love/hate relationship with pain meds. I like helping my patients, I hate only having Fentanyl to do it. There are meds that are more appropriate for some conditions, and I hate only having Fent. I would love to have a non-opiate option, along with a couple of other things.


----------



## abckidsmom (Dec 18, 2010)

Aidey said:


> I personally have found the opposite. Morphine has more side effects, but works better. Occasionally Fent works well in a patient, but more often than not it doesn't do much.
> 
> I have a love/hate relationship with pain meds. I like helping my patients, I hate only having Fentanyl to do it. There are meds that are more appropriate for some conditions, and I hate only having Fent. I would love to have a non-opiate option, along with a couple of other things.



Definitely.

We have a frequent flyer with severe, severe gout, and morphine (all we have) is not appropriate.  I'd love to give the guy some toradol.


----------



## emtpche (Dec 18, 2010)

Well yes more choices would be nice.  I can see if you have only one choice in the toybox looking at what others have may make you want to play with their toys.  

What other non-opitates are there? Tordol's my favorite as most of my drug seekers state they are allergic to it.


----------



## emtpche (Dec 18, 2010)

Well yes more choices would be nice.  I can see if you have only one choice in the toybox looking at what others have may make you want to play with their toys.  

What other non-opitates are there? Tordol's my favorite as most of my drug seekers state they are allergic to it.


----------



## rhan101277 (Dec 18, 2010)

We have toradol but can only give w/ med control orders for things such as kidney stones, sickle cell crysis etc.

20-40 mg IV push..

Morphine is 2-4mg IV q 3-5 min. up to 10max.


----------



## usalsfyre (Dec 18, 2010)

emtpche said:


> While MS works for some folks I find that most require a higher dosage to bring the pain down. Also Fentanyl has less side effects than MS esepcially in  ACS.



My point exactly. My typical fentanyl dose starts around 75 to 100mcg. Which if you beleive the "opiate equivilency chart" is equivelent to 7.5 to 10mgs of morphine. It is easier to titrate fentanyl because if rapid onset, and it has a better side effect profile overall (not just in ACS) but you can certainly get by with morphine. Just not in the homeopathic doses in most protocols.


----------



## Aidey (Dec 18, 2010)

No way in HECK that is accurate. I've had both Fent and Morphine, and 50mcg of Fent was no where close to 5mg of Morphine. 

I remember when I had Morphine I rarely had to use 10mg. I routinely give 50-100mcg of Fent, and have given 200mcg and up multiple times.

I know that is all anecdotal, but I would love to see a side by side real-world comparison study between the two. 

Edit: I would believe it if that was talking about Fentanyl patches. When used chronically it seems to work a lot better than when used acutely.


----------



## emtpche (Dec 18, 2010)

Yes it does have less side effects than MS overall. Berkeley FD did a trial with fentanyl last year focusing on ACS use.  Had really good results and the state has done nothing with it since.  Ooh data scary medics that can think.


----------



## Medic785 (Dec 19, 2010)

Who here is routinely administering Fentanyl via alternative delivery methods such as intranasal or transmucosal on a regular basis?  How has your experience been?


----------



## i5adam8 (Dec 21, 2010)

My medical control authority just changed it's protocols within the last 2 months to include giving Paramedics the authority to give morphine and Fentanyl pre radio. Since giving the two meds I have seen a lot more success with morphine which is the exact opposite of what I expected.


----------



## Melclin (Dec 21, 2010)

Medic785 said:


> Who here is routinely administering Fentanyl via alternative delivery methods such as intranasal or transmucosal on a regular basis?  How has your experience been?



We have IN fent here in Victoria. I've only ever seen it work pretty well, but a lot of people don't like it. Its great to have another option. 

Anecdotally:
-It provides less pain relief, has a longer onset time, and is more unpredictable (side effects wise) when used in older people. Works pretty fast & well in us young ones. 
-Clearing the nose (snorking, blowing, wiping) as much as possible seems to help with the predictability of effect and onset. 
-It doesn't have that fast onset like our other two pain relief options. So I think it creates this affect whereby you don't get that moment where the pt says, "Oh that's much better" so you don't _feel_ like its as good. 
-You have to be liberal with doses, but they have to be tailored to the person. If you put your IV dose up their nose instead and leave it at that, I suspect that you're unlikely to get much of an affect. Starting max dose in a healthy person is 200mcg here, with subsequent 50mcg doses q5. Problem is you can't give that same set of doses to 83 year old granny who weighs 54 kilos.


----------



## medicRob (Dec 21, 2010)

*I just have to vent..*

The other night, I did a floating shift in the ER of a busy trauma I center. Long story short, I had a patient who came in complaining of severe pain in his tooth, and when I had him open up to examine, sure enough his back molar was covered in blood with a huge hole in it.. I asked him how long he had let that go on.. He replied, "This started over 3 weeks ago, and I have no insurance.. ", to which I said, "well, why didn't you come here earlier? We can't deny you treatment on the basis of no insurance."

The patient replied with something that got me so pissed with our system today. He said with the look of desperation in his eyes, as he held his jaw, "I was afraid they would label me as a drug seeker"..

We have to quit this s### about withholding pain meds cause we have an inclination that the patient may be faking the pain. Last time I checked, my nursing textbooks told me that the patient has the right to not be in pain and that we, as providers cannot definitively say "Yes, this person is in pain" or "No, this person is not". Patients come to us in times of desperation for help and put their confidence in our abilities to do so. If my patient tells me they are in pain, and I believe that pain is to a level that would require pain medicine, I will go through the appropriate steps to administer it, whether it be something that requires me to contact medical control to ask for permission or if it is standing order. This patient went for 3 weeks with a tooth that was abcessed so horribly that the entire right side of his face was swollen, all because he was afraid someone would label him a "Drug Seeker". Thank God he came to us when he did so the doc could first and foremost give him antibiotics, the number of a dentist that helped people without insurance, an application for Tenncare, and a prescription for a few hydrocodone. 

I am getting irked just typing this, it pisses me off so much.


----------



## WTEngel (Dec 22, 2010)

I agree. Part of being a patient advocate is giving our patients the benefit of the doubt. If they say they are in pain, we should believe them and try to treat it.

Frankly someone being a drug seeker isn't of too much concern to me. I don't want to contribute to anyone's drug addiction, but I certainly don't want to withhold pain medication from a patient in pain...which I risk if I decide to withhold meds.


----------



## medicRob (Dec 22, 2010)

WTEngel said:


> I agree. Part of being a patient advocate is giving our patients the benefit of the doubt. If they say they are in pain, we should believe them and try to treat it.
> 
> Frankly someone being a drug seeker isn't of too much concern to me. I don't want to contribute to anyone's drug addiction, but I certainly don't want to withhold pain medication from a patient in pain...which I risk if I decide to withhold meds.



The consequences of giving a junky another fix is far less than the consequences of withholding pain management from a patient who actually needs it. Therefore, as long as I can administer pain meds and the patient is physiologically sound enough to maintain such medications, I will give them with respect to the severity and duration of the pain in question.


----------



## rhan101277 (Dec 22, 2010)

I had a medic once tell me that their pain isn't going to kill them.  Maybe so, I think many who withhold pain medicine are just lazy and do not want to fill out the paperwork.


----------



## rhan101277 (Dec 22, 2010)

Linuss said:


> "Would you like something for the pain?"
> 
> 
> If yes, give it.  If slapped on the hand for it not being a 5, then everyone in pain becomes a 5.



Yes I remember reading this somewhere.  I will start trying it.  If they say "yes" then they get at least a six out of 10.


----------



## johnrsemt (Dec 23, 2010)

I used to work with alot of medics who stated that they did not want to cause their patients to 'become addicted' to pain meds.

  there is a major Level I Trauma Center in the Midwest that has been doing an ongoing study for over 7 years about that:   they have had 3 patients out of over 100,000 that have been given pre hospital pain meds that have come out of the hospital addicted:  all 3 were in the ICU for over 2 weeks and 2 were addicts before hand.

   I treat my patients to the best of my ability and alot of times that is treat pain.  So I do


----------



## Dave 52-4 (Dec 23, 2010)

I tend to look at my assessment objectively rather then taking a singular subjective complaint at face value. 

DOI, MOI, objective findings in my secondary assessment. 

1) Pain never caused anyone to expire.
2) Masking what should be obvious symptoms to the receiving physician I think a mistake.

With that said I find myself using MS04 in cardiac settings a great deal more then general medical issues. Trauma being the exception and even then I find good splinting and positioning the key to a good trip.

At the end of the day I follow my my standing orders realizing they are a simple guide, not the law. One size does not fit all.

I do not with hold it, but, it ain't candy on the shelf at Walmart either. BTW we carry Fent, MS, and Demerol. 

Just my thoughts.


----------



## usalsfyre (Dec 23, 2010)

Dave 52-4 said:


> I tend to look at my assessment objectively rather then taking a singular subjective complaint at face value.
> 
> DOI, MOI, objective findings in my secondary assessment.



Curious as to how you objectively evaluate a purely subjective complaint. 



Dave 52-4 said:


> 1) Pain never caused anyone to expire.
> 2) Masking what should be obvious symptoms to the receiving physician I think a mistake.



1.Prove it. You can't anymore than I can prove it did
2.Properly administered pain control AIDS in diagnostic efforts. Studies back this up.



Dave 52-4 said:


> With that said I find myself using MS04 in cardiac settings a great deal more then general medical issues.


So an MI is more worthy of appropriate treatment than say cholecystitis or renal colic?


Dave 52-4 said:


> Trauma being the exception and even then I find good splinting and positioning the key to a good trip.


You find it is or do your patients?



Dave 52-4 said:


> At the end of the day I follow my my standing orders realizing they are a simple guide, not the law. One size does not fit all.



Agreed, but what you described is text book crappy EMS pain management. Let the patient suffer, because we're scared of narcs.



Dave 52-4 said:


> I do not with hold it, but, it ain't candy on the shelf at Walmart either. BTW we carry Fent, MS, and Demerol.
> 
> Just my thoughts.



That's a contradictory statement if I ever heard one, not to mention you admitted to withholding meds from medical patients earlier. What harm is the small amount of narcotics you administer (assuming you do it appropriately) going to cause? When you can articulate that, come back to me.


----------



## Jay (Dec 23, 2010)

rhan101277 said:


> Anyhow our protocols say that pain management is indicated on any isolated extremity injury with pain scale greater than 5 out of 10.



That's Poppycock! How about they become proponents of treating the patient and not their numbers. Every service, hospital is different, for example VA Hospitals use 7 or above for their number, others 6, etc. But you can usually tell if someone is in severe pain and based off of how they present, an educated (pronounced "fair") responder will treat pain based off of that. The other problem is that a "broken finger" for one may not be as bad as a kidney stone or as bad as back pain with someone with severe stenosis. Since 85% (or around that number) of pain is idiopathic anyways, the treatment needs to be based off of several factors that would ultimately be beneficial to the welfare of the patient.

Also, many of times I discovered that copious O2 will drastically reduce the pain reported after 5 minutes, this goes for MI or trauma. Each patient is different though.


----------



## Dave 52-4 (Dec 23, 2010)

usalsfyre said:


> Curious as to how you objectively evaluate a purely subjective complaint. It is rather easy, it is called a secondary assessment, ergo, what I typed above, DOI, MOI add to that a pertinent history and whala you are actually doing your job
> 
> 
> 
> ...



I have little time for cookie cutter medics that do not have the knowledge, skill or were with all to access a patient, when you get to that level, look me up. But be it known, I am always willing to teach, ALWAYS....

Be well.


----------



## Smash (Dec 23, 2010)

Dave 52-4 said:


> I tend to look at my assessment objectively rather then taking a singular subjective complaint at face value.
> 
> DOI, MOI, objective findings in my secondary assessment.
> 
> 1) Pain never caused anyone to expire.


Perhaps not, but it causes increased length of stay in hospital, poorer prognosis from multiple disease process, modifies inflammatory and coagulatory processes, increases the rates of re-presentation and readmittance, causes loss of function, depression, anxiety, insomnia.... the list goes on.



> 2) Masking what should be obvious symptoms to the receiving physician I think a mistake.



Good God, Zachary Cope is dead, can't we put his ghost to rest as well?  As usalsfyre has pointed out, analgesia is useful in aiding diagnosis, not masking it.  It allows the the blunting of the distress that comes with pain (the affective part of pain) so that the patient can more accurately describe the pain and other symptoms without being distressed and distracted:

Dahl JL, Berry P, Stevenson KM, Gordon DB, Ward S. Institutionalizing pain management: Making pain assessment and treatment an integral part of the nation's healthcare system. APS Bulletin 1998; 8(4): 6. (s)

Wolfe JM, Lein DY, Lenkoski K, Smithline HA. Analgesic administration to patients with an acute abdomen: a survey of emergency medicine physicians. AmJ Emerg Med 2000; 18:250-253. (s)

Pace S, Burke TF. Intravenous morphine for early pain relief in patients with acute abdominal pain. Acad Emerg Med 1996; 3:1086-1092. (s)

Attard AR; Corlett MJ; Kidner NJ; Leslie AP; Fraser IA. Safety of early pain relief for acute abdominal pain. Br Med J 1992; 305: 554-556. (s)

Thomas SH, Silen W, Cheema F, Reisner A, Aman S, Goldstein JN et al. Effects of morphine analgesia on diagnostic accuracy in emergency department patients with abdominal pain: a prospective, randomized trial. J Am Coll Surg 2003; 196(1): 18-31. (s)

Wolfe JM, Smithline HA, Phipen S, Montano G, Garb JL, Fiallo V. Does morphine change the physical examination in patients with acute appendicitis? Am J Emerg Med 2004; 22(4): 280-285. (s)

Kim MK, Strait RT, Sato TT, Hennes HM. A randomized clinical trial of analgesia in children with acute abdominal pain. Acad Emerg Med 2002; 9: 281-287. (s)

Thomas SH, Silen W. Effect on diagnostic efficiency of analgesia for undifferentiated abdominal pain. Br J Surg 2003; 90: 5-9. (s)

Mahadevan M, Graff L. Prospective randomized study of analgesic use for ED patients with right lower quadrant abdominal pain. Am J Emerg Med 2000; 18: 753-756. (s)

LoVecchio F; Oster N; Sturmann K; Nelson LS; Flashner S; Finger R. The use of analgesics in patients with acute abdominal pain. J Emerg Med 1997; 15: 775-779. (s)

Vermeulen B, Morabia A, Unger PF, Goehring C, Grangier C, Skljarov I, Terrier F. Acute appendicitis: influence of early pain relief on the accuracy of clinical and US findings in the decision to operate--a randomized trial. Radiology 1999; 210: 639-643. (s)

Nissman SA; Kaplan LJ; Mann BD. Critically reappraising the literature-driven practice of analgesia administration for acute abdominal pain in the emergency room prior to surgical evaluation. Am J Surg 2003; 185(4): 291-296. (s)

Manterola C, Vial M,Moraga J, Astudillo P. Analgesia in patients with acute abdominal pain. Cochrane Database of Systematic Reviews 2007, Issue 3.



> _So an MI is more worthy of appropriate treatment than say cholecystitis or renal colic?_ Yep, that's right an MI will kill you en route renal colic is a taxi cab issue, even in Dialysis patients



I'm blown away by that comment.  My only hope is that I never suffer from such an illness in your patch of the woods, or maybe that you do in someone else's who has the same attitude.

I'm pleased you are always willing to teach; I'm just not sure that I would like people learning this approach to patient care.


----------



## alphatrauma (Dec 23, 2010)

medicRob said:


> I don't withhold pain meds. If I believe my patient is in pain or my patient tells me they are in pain,  I will administer them. I will leave it to the ER docs to play the little, "Who's a drug seeker game" .. I personally try not to pass such judgements.



^ This!


----------



## Dave 52-4 (Dec 23, 2010)

Smash said:


> I'm pleased you are always willing to teach; I'm just not sure that I would like people learning this approach to patient care.



To each their own, I believe that there are many roads that lead to the same fruition in any given scenario. With good medical direction, a quality QA/QCI program that includes agressive training I believe these issues would be nill at best.

I, again, never stated pain control should not be used, my point is that it should be based upon sound assessment and good judgement, not dispensed in a cookie cutter fashion - IE anyone everywhere. 

Good points made here however, yours included.


----------



## usalsfyre (Dec 23, 2010)

> It is rather easy, it is called a secondary assessment, ergo, what I typed above, DOI, MOI add to that a pertinent history and whala you are actually doing your job



Again, please explain to me how you asses this? Pain is by all measures a SUBJECTIVE complaint. I know of no one who has figure out how to truly objectively asses pain (but I have met lots of people who think they can). 



> Name your studies ad-hoc or not, would love to see them..Maybe I would learn something, that is why we are all here at the end of the day



See Smash's post 



> Yep, that's right an MI will kill you en route renal colic is a taxi cab issue, even in Dialysis patients



Considering dialysis patients aren't using their kidneys for elimination I would hope not. However, remind me to never have an extremely painful, yet non-life threatening in the view of EMS, condition in your town. Because the care I would get would be substandard. 



> I have had a rather large success with positioning and splinting, but, that takes time and energy, more so the sticking an 18 short and breaking a plastic lock



So I'm not sure exactly what your trying to say here (local terminology?) but I find positioning and splinting to be very helpful as well. I also find a good dose of fentanyl IN or IV BEFORE I start performing a potentially painful procedure (splinting) makes my patients much happier and easiser to deal with. If I could, I'd slip them some midaz as well to make the experince much more pleasant/foregetable. 



> that is not what I said, re-read my post.



Then explain how it means something different. 



> I have little time for cookie cutter medics that do not have the knowledge, skill or were with all to access a patient, when you get to that level, look me up. But be it known, I am always willing to teach, ALWAYS....



Very, very far from a cookie cutter medic here. I'm always willing to learn, but I have a feeling you have very little to teach on this subject. You describe the typical paramedic approach to pain, "it's not important enough for me to deal with". 

If you are so willing to teach, please explain to me why pain management is  bad, why letting patients suffer is good, and how one or two doses of narcotics, administered correctly, for painful but "non-emergency" conditions is detrimetal to patient care?


----------



## mc400 (Dec 23, 2010)

I withhold pain meds very rarely. If you tell me you are in pain and it is within my protocol to help ease that pain I will do so. Many of my transport times are 20-40 minutes so some zofran usually comes with it too. We only carry MS but hopefully soon fentanyl will be available. 

Not treting pain is a thing of the past. Also I agree with usal splinting and positioning is much easier and less painful fr the pt if there is some drugs on board, we always try to give MS and depending on the patient a benzo when positioning and splinting a fracture or moving a fractured hip/femoral head patient. It makes no sense not too.


----------



## jjesusfreak01 (Dec 23, 2010)

Have to agree here. There is no reason in EMS to withhold pain medications. They have short half-lives, so honestly if you want a high, EMS isn't the best way to do it. Now, drug seekers at the hospital are another problem entirely...


----------



## Veneficus (Dec 23, 2010)

As for objectifying pain, I tend to use the FLACC scale. It helps not only with children or the cognitively impaired but also with those who cannnot be effectively communicated with like languages I don't speak.

Personally I always err on the side of the patient. Nobody will ever rightfully accuse me of not liberally treating pain.

Even if you have to call med control sometimes a benzo and opioid mix will go father than simple high dose opioids.

Medicine cannot cure all ills, but since the very foundation it has had the ability to reduce pain.

There are actually conditions where the pain is diagnostic, but I advocate finding another way. Since we have the means in 2010, leaving a patient in pain is just outright mean.


----------



## Shishkabob (Dec 23, 2010)

Someone at my agency screwed the pooch with our pain control.  Up until last week, we had 1-2mcg/kg Fentanyl for anyone in pain, can be repeated without consult, and if pain still wasn't controlled we could consult with MC about RSIing.

Well, got a memo last week... now it's just 1mcg/kg for people above 10years and below 70years.  (Though we can still do 3mcg/kg as pre-medication for RSI)


----------



## Smash (Dec 23, 2010)

Linuss said:


> Someone at my agency screwed the pooch with our pain control.  Up until last week, we had 1-2mcg/kg Fentanyl for anyone in pain, can be repeated without consult, and if pain still wasn't controlled we could consult with MC about RSIing.
> 
> Well, got a memo last week... now it's just 1mcg/kg for people above 10years and below 70years.  (Though we can still do 3mcg/kg as pre-medication for RSI)



How does med control feel about RSI for pain relief only?  Does it happen often, and in what sort of settings? I presume the rationale is to allow heroic doses of sedation and analgesia to manage pain without fear of respiratory/airway compromise.


----------



## Shishkabob (Dec 23, 2010)

To be honest, I'm too new here to know how often it's used, usalfyre will be of better assistance there, but yes I would presume it would be in an attempt to give ungodly amounts of narcotics as, atleast in my county, we're 45min-1hr+ away from anything that resembles a hospital.


----------



## MrBrown (Dec 23, 2010)

One of the most important aspects of prehopital medicine is the sufficent relief of pain.  Pain is nasty, it has negative physiologic and psychologic effects and is just plain uncomfortable.  

We take an agressive approach to analgesia with a wide selection of analgesics (paracetamol, methoxyflurane, morphine +/- midaz, ketamine) as well as traditional non-medication based modalities eg splinting, positioning.

Nobody should be witheld pain medication for fear of "masking symptoms" or "they are a druggie" or because "pain never killed anybody".  

If you are in pain, you should get something for it.  End of story.


----------



## Smash (Dec 23, 2010)

Linuss said:


> To be honest, I'm too new here to know how often it's used, usalfyre will be of better assistance there, but yes I would presume it would be in an attempt to give ungodly amounts of narcotics as, atleast in my county, we're 45min-1hr+ away from anything that resembles a hospital.



It's a hell of a step to take.  Not saying that it is bad, good or indifferent, merely that it is a big step.  Personally I would probably prefer to have something like ketamine in my bag of tricks for a start, but then if you have long transports and something like major burns, it is probably the humane thing to do anyway.


----------



## Shishkabob (Dec 23, 2010)

On our ground trucks we only carry Fentanyl for analgesia and Ativan / Versed for sedation (Not including Etomidate and Roc for RSI).  Our flight crew, though, gets Morphine and Ketamine as well. 

Plus if it ends up being a burn, chances are the chopper was auto-launched, and they'll get a tube and a hop on over to Parkland.



But it's an option, and I like having the ability to have options.


----------



## Dave 52-4 (Dec 24, 2010)

usalsfyre said:


> Then explain how it means something different.
> QUOTE]
> 
> The main thrust of my point (as I do not argue) is that we must refrain from treating the protocol and not the patient. Pain is a consequence of injury, it is a natural responce. Any primate if taught and rewarded well can follow an algorithm. We have to think, we have to assess.
> ...


----------



## usalsfyre (Dec 24, 2010)

Dave 52-4 said:


> The main thrust of my point (as I do not argue) is that we must refrain from treating the protocol and not the patient.


Absoloutely



Dave 52-4 said:


> Do I treat pain daily , sure I do, but I am not grandiose with my manner to think I can act as a cure all.



Has nothing to do with being a cure all. It has to do with relieving a patient's suffering and being humane. 



Dave 52-4 said:


> You want to treat a belly pain with a fist full of Morphine, Fent, whatever so beit, but, the second you bottom a pressure secondary to narcotics and infarct a patient because "that is what the protocol states", treated a subjective complaint without a full and methodical assessment - Fine. I have never made that mistake yet, from the talent I see here in the written form I doubt many others have either.



Fent is VERY hemodynamicly stable, so much so it is the cardiac anesthia agent of choice. Very seriously doubt you'll "bottom them out and infarct them" unless you just completely miss the signs of massive, massive shock. 



Dave 52-4 said:


> Is it renal colic, or is it referred pain from a minuscule leak in the descending aorta secondary to HTN...If your that good let me know when your next lecture is, I will be in the front row.
> 
> Renal Colic? Really? I mean really? You ciphered that in the back of your truck in the first five minutes? .



I chose renal colic/renal stones because it is one of the easier diagnosis to make of physical exam alone. Ask an ED doc if the REALLY need imaging to do it.



Dave 52-4 said:


> I know many services that have had RSI taken away because of a low ETT placement rates and lack of a true prehospital assessment, where I work we still have it, because we assess, because we do not look at things like pain control as a right versus a definitive diagnoses.



My service has very agressive RSI protocols, does ALOT of RSIs, has first pass succes rates in th 98% range last time I checked and views pain management as an approprite treatment of patient symptoms.  



Dave 52-4 said:


> To those who say 2 mg's of MS04 wont hurt are are living a misnomer, 2mg of Morphine in the face of a true fracture is symbolism over substance, in other words - useless...



Agreed



Dave 52-4 said:


> If, after an objective assessment pain is a true possibility, it should be treated, and treated in an aggressive manner...Other wise this is bunk really.
> 
> JMO, many have others.



My point is pain management should be ruled out rather than ruled in. I don't need to find a reason to treat pain, I need to find a darn good reason I SHOULDN'T treat it. Anything else is quite frankly cruel. We need to get over our misgivings about pain management, and do what we should have been focusing on all along, relieving suffering.


----------



## usalsfyre (Dec 24, 2010)

Smash said:


> How does med control feel about RSI for pain relief only?  Does it happen often, and in what sort of settings? I presume the rationale is to allow heroic doses of sedation and analgesia to manage pain without fear of respiratory/airway compromise.



Absoloutely why we have it in the protocol, I haven't personally heard of it being done though.


----------



## Dave 52-4 (Dec 25, 2010)

usalsfyre said:


> My point is pain management should be ruled out rather than ruled in. I don't need to find a reason to treat pain, I need to find a darn good reason I SHOULDN'T treat it. Anything else is quite frankly cruel. We need to get over our misgivings about pain management, and do what we should have been focusing on all along, relieving suffering.



Nice points and I totally agree, I think we are the same path here as we rule "things in or out" through an agressive assessment. 

Merry Christmas!

Be Well.


----------



## usafmedic45 (Dec 26, 2010)

> What other non-opitates are there?



Ketamine. 



> How does med control feel about RSI for pain relief only? Does it happen often, and in what sort of settings? I presume the rationale is to allow heroic doses of sedation and analgesia to manage pain without fear of respiratory/airway compromise.



Once again, ketamine.  

Honestly, it's one of my favorite drugs for anyone in severe pain: it's got neuroprotective effects, it causes bronchodilation, you don't lose your drive to breath or your protective airway reflexes and the patient is comfortable and cooperative.



> I know many services that have had RSI taken away because of a low ETT placement rates



That's when you stop looking at ETI and "airway control" being the same thing and manage the airway however it needs to be managed.  If you need to drop a Combitube, do it.  Once they are down and have an airway secured by whatever means work, there's no reason to complain about "failed intubation".  This is one of my biggest pet peeves and one of the things I talk about in my conference presentations.


----------



## Smash (Dec 26, 2010)

usafmedic45 said:


> Once again, ketamine.
> 
> Honestly, it's one of my favorite drugs for anyone in severe pain: it's got neuroprotective effects, it causes bronchodilation, you don't lose your drive to breath or your protective airway reflexes and the patient is comfortable and cooperative.



Yeah, I know, I was surprised at the use of RSI rather than ketamine 





			
				Smash said:
			
		

> Personally I would probably prefer to have something like ketamine in my bag of tricks



I understand the rationale, but ketamine is just such a useful and safe drug I don't understand why everyone doesn't have it.


----------



## usalsfyre (Dec 26, 2010)

But, but, people get _high_ on ketamine...

I agree, and wish we had ketamine at both analgesic and induction doses. However some of our ED docs seem uncomfortable with using it in the ED, much less on the trucks, citing concerns over emergence, misuse, security, diversion ect. I think alot of the push back is due to the area (we are rural Bible belt) and worries over the public finding out we gave little Johnny and acid trip after he suffered 3rd degree burns (although who _*wouldn't*_ want an acid trip after that?).RSI is an incredibly invasive answer to the problem. Give it a little time, maybe when ketamine is more safely established in the US (I know they've been using it for years overseas) and maybe we'll see it.


----------



## Veneficus (Dec 26, 2010)

usalsfyre said:


> But, but, people get _high_ on ketamine...
> 
> I agree, and wish we had ketamine at both analgesic and induction doses. However some of our ED docs seem uncomfortable with using it in the ED, much less on the trucks, citing concerns over emergence, misuse, security, diversion ect. I think alot of the push back is due to the area (we are rural Bible belt) and worries over the public finding out we gave little Johnny and acid trip after he suffered 3rd degree burns (although who _*wouldn't*_ want an acid trip after that?).RSI is an incredibly invasive answer to the problem. Give it a little time, maybe when ketamine is more safely established in the US (I know they've been using it for years overseas) and maybe we'll see it.



First and foremost, good to see you back. Happy Holiday.

But I wouldn't expect too much in the way of "advancement" in pain management, especially with ketamine in the US for the adult populations. (it is used mostly in peds) 

The first problem is a new physician is likely to use what the old physician taught her. Which largely excludes ketamine.

Another major problem is some states, like my home, are trying to find a way to hold doctors responsible for patients who get addicted to prescription drugs. So pain management outside of the specialty isn't likely to be taking great leaps forward.

Finally, bible belt or not, US medicine can only be described as "adverse" to treating pain. There are still senior surgeons who like the idea of leaving a patient in pain to see if abd pain worsens instead of a serial ultrasound or CT scan. There are still other providers on a grand scale who think controlling pain will somehow mask something life threatening. Let's not forget the punitive medicine crowd who decides patients don't deserve or shouldn't be in that much pain. 

Top it all off with an unhealthy dose of unfounded fear among a majority of providers who feel that proper pain management will result in death and all other kinds of worse than death scenarios.   

Example, EMS with 2mg per dose max 10mg of morphine.

Indicated dose for analgesia, 0.15 mg/kg

a 70kg pt should recieve an initial dose of 10.5mg I think we both know that will never happen.

Even with newer things like fent, which has less "side effects" the doses are often limited to 50-100ug. 

How about benzo/opioid synergy, 2-4mg morphine and 2-4mg versed, to treat nociceptive and psychological pain and in as little as 4-8mg total, you can all but absolve pain in most adults. Best of all the versed has very potentent amnestic effects, which really helps with kids, even in doses much smaller than conscious sedation.

But you won't even see EDs in the US using or even considering it. Even in patient populationss who have more psych aspect to their pain than nociceptive.

RSI for pain control? For irretractable pain in the most extreme of circumstances perhaps. But I can't really see it as an alternative just because the fent didn't work.


----------



## MrBrown (Dec 26, 2010)

Seriously people ketamine FTW .... its the most awesome thing since we got nubain and foratol in the early 1990s


----------



## johnrsemt (Dec 26, 2010)

I have given a patient 100mcg Fentanyl * 2 6 min apart,  when starting B/P was 66/20 due to partial amputation of hand with severe bleeding.   Called for orders for 50 mcg,  Doc yelled at me on phone and told me to give 100mcg.   
   pain went away and B/P went up to almost 100/60.


----------



## ClarkKent (Dec 26, 2010)

rhan101277 said:


> I think many who withhold pain medicine are just lazy and do not want to fill out the paperwork.



I know that I am only and EMT-B (and not working as one), but for pushing MS, is there really that much more paper work todo?  Is it just one more check mark you have to make on the PCR, or is there a whole book that you have to fill out just because someone need help with pain management?  Just asking


----------



## usalsfyre (Dec 26, 2010)

ClarkKent said:


> I know that I am only and EMT-B (and not working as one), but for pushing MS, is there really that much more paper work todo?  Is it just one more check mark you have to make on the PCR, or is there a whole book that you have to fill out just because someone need help with pain management?  Just asking



There's some doccumentation realted to administering a controlled substance, and the doccumentation guidlines are usually a bit stricter as far as what goes in the PCR.


----------



## Smash (Dec 27, 2010)

Veneficus said:


> Another major problem is some states, like my home, are trying to find a way to hold doctors responsible for patients who get addicted to prescription drugs.



What?  No, what?  But... no.... what?  Serious?  But that is just... what?  Who could possibly think that that could.... what?  Sorry, I just can't comprehend such a thing at all.

My god, what a pathetic state of affairs.


----------



## vquintessence (Dec 27, 2010)

Smash said:


> What?  No, what?  But... no.... what?  Serious?  But that is just... what?  Who could possibly think that that could.... what?  Sorry, I just can't comprehend such a thing at all.
> 
> My god, what a pathetic state of affairs.



But not at all shocking, given that drug dependency has become a disease that makes the afflicted eligible for SS, gov't housing and transportation assistance.

NOBODY takes personal responsibility anymore (in US at least..).  It's always the fault of the deepest pockets.

It's McDonalds fault that my kid is fat.
It's my elderly neighbors fault I slipped on ice on their sidewalk property at 03:00 during a snowstorm.
It's the dog owners fault that I got bit while burglarizing their home while they're away.


----------



## MrBrown (Dec 27, 2010)

You my friend are correct; there is no personal responsibility anymore.


----------



## socalmedic (Dec 27, 2010)

ClarkKent said:


> ...for pushing MS, is there really that much more paper work todo?...



yes, about 2 pages. they are short pages, but you do have to call the supervisor to get a refill. which means you actually have to finish your paperwork right after the call. I personally have no problem doing this, i do not consider the call complete until the paperwork is done. I do not know of any medics who would withhold pain management due to the paperwork, but i am sure they are out there.


----------



## socalmedic (Dec 27, 2010)

vquintessence said:


> nobody takes personal responsibility anymore (in us at least..).  It's always the fault of the deepest pockets.
> 
> It's mcdonalds fault that my kid is fat.
> It's my elderly neighbors fault i slipped on ice on their sidewalk property at 03:00 during a snowstorm.
> It's the dog owners fault that i got bit while burglarizing their home while they're away.



+ 1


----------

