[Separated] Give drugs to drug seekers

[usalsfyre]

My understanding is Wong-Baker is not really designed to be used in the conversant patient.

While I agree a dearth of pain management options (PO NSAIDS or narcotics being chief among the missing options) is a problem, I ask again, why exactly do we care if we get "tricked"?

 

[bigbaldguy]

Picked up a guy from a job site once. His hand had gotten caught between two steel i beams that were being rolled. Crushed hand, partial amputation of 4 fingers significant de glove of what was left. We ask the guy what his pain is 1 to 10 he says "not too bad maybe a 5". Huh? Screw that, medic already has the Fent ready so he administers it. After the fent kicks in the guy visibly relaxes. Was the guy just a steel core stoic Mofo or was it just shock, who cares either way the guy felt better after the Fent, and that's what it's all about right? When I see a medic refuse to give meds to someone who says they have 10/10 I think about that guy and the kind of pain he was probably in. If I were to withhold pain meds from one person who was in as much pain as that guy was because they might be a drug seeker and it turned out I was wrong? I've done some horrible things but I think that would go right at the top of the list.

 

[bigbaldguy]

I never withold pain meds, but I can't help but think that if drug seekers weren't given opioid analgesia by EMS and ED staff, then they would stop calling 911?

There has to be a way of stopping the repeating cycle. Why would anyone in my state try to buy drugs on the street / commit crimes to pay for them, when they can call 000 (911) get an ambulance straight away, lie to receive opioids, lie to the hospital and not get charged a single penny.

So you're saying it's better that people commit crimes rather than call 911 cuz then they don't have to pay...for....huh? I'm confused.

 

[medicsb]

My understanding is Wong-Baker is not really designed to be used in the conversant patient.

While I agree a dearth of pain management options (PO NSAIDS or narcotics being chief among the missing options) is a problem, I ask again, why exactly do we care if we get "tricked"?

Technically, you're supposed to instruct the pt. to pick a face that corresponds to their level of pain, but many use it for patient who are nonverbal. I admit, I don't use it exactly as it is supposed to, but it can provide insight for QA as the local health system Wong-baker faces has some descriptions associated with the face/# in terms of grimacing, distraction, etc. Anyhow, this is not about being tricked. It's about providing an appropriate level of care based on a proper H&P. Not everyone reporting pain needs IV analgesia.

 

[usalsfyre]

Anyhow, this is not about being tricked. It's about providing an appropriate level of care based on a proper H&P. Not everyone reporting pain needs IV analgesia.

So in the absence of other options you'd rather withhold analgesics rather than go for overkill?

I've been on the other end of that decision (sort of). It sucks.

 

[bigbaldguy]

I find it fascinating that in nearly every area of American life we tend to go for a "more is better" philosophy with two major exeptions, sex Ed and pain/anxiety management.

 

[usalsfyre]

Moral majority baby. Sex is bad and pain management makes addicts.

You can add mental health services availability to your list as well.

 

[bigbaldguy]

Moral majority baby. Sex is bad and pain management makes addicts.

You can add mental health services availability to your list as well.

Crazy people have the devil in em man, why would you want to provide services and housing to people with Satan in em

 

[SteveTP]

^^^Horribly unethical...

I've never understood WHY people care about giving meds to drug seekers. Your withholding them makes no difference at the end of the day.

I disagree, psychosomatic pain and drug addiction both require treatment, and that treatment is not simply to narc them up. Ultimately the question that must be answered is: Is the educational foundation present to allow providers to make decisions with regards to differential diagnosis of pain via saline placebo? That is a question which I cannot answer. I really wouldn't care that a patient pulled the wool over my eyes, I would care if a patient did not recieve proper treatment for their condition. Narcotics for drug addiction is not proper treatment.

The problem with the Tuskegee Study (assuming my recollection of he subject matter is correct) is that there was no potential benefit (to the subject) from witholding information about syphilus status. whereas there is the potential for benefit (to the subject) from temporarily witholding narcotic analgesia. Using a placebo to form a diagnosis may or may not be unethical depending on the situation, whereas witholding treatment for a treatable condition (without consent), "just so we can see what happens" is never ethical.

 

[Handsome Robb]

Going off of this, how do y'all document the pain scale? I don't really like using the 1-10 scale as that is very subjective and is often not accurate at all.

"PT states 10/10 pain when asked to rate their pain on a 10 scale" Then include your findings of your assessment of the area the PT is complaining of pain in.

I agree that we have no right withholding pain meds, but use your head and your assessment alongside what the PT tells you to determine when they are appropriate though.

 

[18G]

How is it unethical? I never said that we withheld the pain meds. After the 10ml flush their pain goes away so there is no need for pain medication. If they want pain medication then they are going to get pain meds. If they say they are in pain they are more then likely going to get pain meds (up to the medics).

This is way out of line and no EMS provider has the right to administer saline for pain. This goes against the standard of care and practically every position out there for pain management. There is no way (unless you have prior knowledge of patients history) of determining in a brief field contact that a patient is only drug seeking. Sure, we may have suspicions but it is not up to us or in our scope of practice to make that determination.

If you truly believe that the patient is BS'ing than you can be passive in your denial by talking more, taking longer to do your assessment, vitals, etc. But again, a patient's pain rating is completely subjective. What the patient feels may not be the same as you would feel. As mentioned, it is a bad practice to try and decide what someone else is feeling.

Who really cares if a patient gets a dose of fentanyl or morphine? If you start to see this patient over and over than yes, you just identified a problem. But first time encounters shouldn't be judged.

I am a great proponent of analgesia and get so tired of out dated attitudes and opinions on using opiates.

 

[usalsfyre]

whereas there is the potential for benefit (to the subject) from temporarily witholding narcotic analgesia

Wanna clue me in on what that is?

Substance abuse is a huge issue. But it's not within EM's (the hospital too) scope to diagnose or treat it, and your withholding pain meds is not going to give them a lifestyle changing moment.

 

[bigbaldguy]

Isn't a symptom of sudden opiate cessation severe cramps and generalized severe pain? Pain's pain right? I have no idea how bad it hurts coming off heroin, but from the couple of cases I've seen I'm guessing it's pretty rough. Sure you could argue that they caused the pain by becoming an addict but you could argue that a guy who broke his leg falling off a horse should have known better than to get on. The pain in either case is real and at least in my opinion should be treated no differently.

Anybody notice what I did there with the heroin/horse thing?

 

[DesertMedic66]

This is way out of line and no EMS provider has the right to administer saline for pain. This goes against the standard of care and practically every position out there for pain management. There is no way (unless you have prior knowledge of patients history) of determining in a brief field contact that a patient is only drug seeking. Sure, we may have suspicions but it is not up to us or in our scope of practice to make that determination.

If you truly believe that the patient is BS'ing than you can be passive in your denial by talking more, taking longer to do your assessment, vitals, etc. But again, a patient's pain rating is completely subjective. What the patient feels may not be the same as you would feel. As mentioned, it is a bad practice to try and decide what someone else is feeling.

Who really cares if a patient gets a dose of fentanyl or morphine? If you start to see this patient over and over than yes, you just identified a problem. But first time encounters shouldn't be judged.

I am a great proponent of analgesia and get so tired of out dated attitudes and opinions on using opiates.

I think you misread what I wrote. The 10ml of Saline is NOT used in anyway as a pain medication. It is used as a flush (what a 10ml preload of saline is for...). The patient is just told if at all that it is saline (nothing more, nothing less). Ive had a couple of patients get instant pain relieve with the saline flush. If they say their pain when away with the flush then why would you give pain medications to a patient who no longer has any pain?

Once again so everyone understands what I am saying: the 10ml saline preload is used as a saline flush, nothing more and nothing less. It is NOT used as any kind of pain medication.

 

[the_negro_puppy]

So you're saying it's better that people commit crimes rather than call 911 cuz then they don't have to pay...for....huh? I'm confused.

I guess i'm more saying that our system is set up to be abused easily without any repercussions. We have state laws existing to punish people who abuse EMS but its nearly impossible to officially determine tnat someone does not need an ambulance (even for a basic assessment)

 

[bigbaldguy]

I guess i'm more saying that our system is set up to be abused easily without any repercussions. We have state laws existing to punish people who abuse EMS but its nearly impossible to officially determine tnat someone does not need an ambulance (even for a basic assessment)

I got yah I just couldn't resist digging yah a little. It's a catch 22, addicts can either break the law to get their narcs or break the law to get their narcs. Pick your evil I suppose.

 

[18G]

I think you misread what I wrote. The 10ml of Saline is NOT used in anyway as a pain medication. It is used as a flush (what a 10ml preload of saline is for...). The patient is just told if at all that it is saline (nothing more, nothing less). Ive had a couple of patients get instant pain relieve with the saline flush. If they say their pain when away with the flush then why would you give pain medications to a patient who no longer has any pain?

Once again so everyone understands what I am saying: the 10ml saline preload is used as a saline flush, nothing more and nothing less. It is NOT used as any kind of pain medication.

I understand perfectly what you are saying and I do not agree with it. I'm not into the practice of "tricking" my patients or lying to them by an act of omission.

Your injecting a fluid into a patient that is not indicated and providing care on a false pretense which isn't cool. Yes, it is only NSS and isn't going to hurt them but the principle in practice is the issue. Are you documenting in your PCR that the patient was having pain and you treated them with 10mL of NSS?

If the patient is having pain, get them pain medication. If it is beyond your scope than call for ALS or the patient waits until they get to the hospital.

 

[SteveTP]

Wanna clue me in on what that is?

Substance abuse is a huge issue. But it's not within EM's (the hospital too) scope to diagnose or treat it, and your withholding pain meds is not going to give them a lifestyle changing moment.

I think we probably approached the issue from different angles, while I looked at it from a hypothetical angle, you looked at it in the more practical sense, directly applicable to EMS presently. I probably would have been better off using multi-quote for clarity.

My point was that if educational standards and mission changed (notwithstanding potential personal freedom issues), It would be possible to withold analgesia ethically. While Tuskegee is unethical no matter what, witholding analgesia can be ethical as a form of diagnosis (more for psychosomatic illness).

I absolutely agree with you that substance abuse intervention is not within our scope, and that presently witholding analgesia is unethical (witholding narcotics, in my view is ethical, as long as a suitable non-narcotic form of pain relief is available) . While it would be great if we could treat substance abuse, it really isnt all that practical, and not giving them morphine really wont turn them into productive members of society. What we should do,for now at least, is encourage them to seek treatment and attempt to connect them to the most effective pathways for treatment, anything less is failing to provide the highest level of care to a patient

 

[DesertMedic66]

I understand perfectly what you are saying and I do not agree with it. I'm not into the practice of "tricking" my patients or lying to them by an act of omission.

Your injecting a fluid into a patient that is not indicated and providing care on a false pretense which isn't cool. Yes, it is only NSS and isn't going to hurt them but the principle in practice is the issue.

If the patient is having pain, get them pain medication. If it is beyond your scope than call for ALS or the patient waits until they get to the hospital.

No your still not understanding me. The patient is not tricked in any way. The patient is not lied to. The medic will get a saline lock on scene. Then they will use the flush to flush out the line. NS flush is called for that. After it is flushed they will connect the IV tubing so they can inject the pain medication into the tubing thru the port.

As soon as the flush is done we connect the tubing. We don't give the flush and then wait. The NS flush is used as only a flush to clear the cath and then the line is connected. In no way is it used as a pain medication.

 

[Sasha]

I don't understand people's drug seeker radar.

Do you think by with holding the medication you are going to cure them of their habit?

All you're doing is starting them through the whole withdrawal roller coaster which causes pain.

Pain that you should be treating.

And please keep in mind, drug seekers CAN feel pain.