is a broken arm an ALS or BLS call?

is a broken arm an ALS or BLS call?

  • ALS (with Paramedics)

    Votes: 33 29.5%
  • BLS (EMT only)

    Votes: 79 70.5%

  • Total voters
    112

FiremanMike

Just a dude
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Not (necessarily) taking a side here but doesn’t categorizing this as a BLS call effectively equal refusing to give pain meds?

Not necessarily, I think they’re two separate discussions.

Then again I work in an area without any BLS transport units, so that should be taken into account.. I’ve never “turfed” a run to the squad because it’s never been an option for me..
 

CCCSD

Forum Deputy Chief
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Isn’t an Icepack pain control? Ibuprofen, etc?

I AM a fan of fentanyl lollies though...
 

akflightmedic

Forum Deputy Chief
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Position of comfort. Splinting. Mindfulness. Square breathing.
 

Peak

ED/Prehospital Registered Nurse
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Not (necessarily) taking a side here but doesn’t categorizing this as a BLS call effectively equal refusing to give pain meds?
Isn’t an Icepack pain control? Ibuprofen, etc?

I AM a fan of fentanyl lollies though...

The application of a splint is pain control. Ice packs, hot packs on chronic injuries, range of motion, distraction, minimizing stimulation, music, and so on can all decrease pain.

When we do look at meds there are a lot of very effective options that are non-opioid, granted to a more limited availability in EMS. Tylenol, NSAIDs, Robaxin, Flexeril, lidocaine patches, blocks, and so on. When we are able to use things like the on q ball we see better pain management and our narcotic use drops substantially. I’ve had hip fractures where we don’t have to give any narcotics once the patient gets a fascia iliaca block for sometimes well over a day.
 
OP
OP
DrParasite

DrParasite

The fire extinguisher is not just for show
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Not (necessarily) taking a side here but doesn’t categorizing this as a BLS call effectively equal refusing to give pain meds?
As the OP on this, the answer is sometimes.

If you have a BLS 911 crew, should they request an ALS unit to administer pain meds, and no other intervention?

if you are an ALS truck, are ALS pain meds appropriate to give for a broken arm? Does it depend on how much pain the patient is in? if the patient demands pain meds, does that mean a paramedic SHALL give the patient pain meds? Even if they aren't clinically indicated?
I AM a fan of fentanyl lollies though...
I've heard of them... If we can give them to the BLS crews, does that mean they don't need to tie up an ALS unit, and still provide some pain management?
 

RocketMedic

Californian, Lost in Texas
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I’m super-glad I got fentanyl and ketamine when I ripped my finger open instead of square breathing.
 

FiremanMike

Just a dude
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The application of a splint is pain control. Ice packs, hot packs on chronic injuries, range of motion, distraction, minimizing stimulation, music, and so on can all decrease pain.

When we do look at meds there are a lot of very effective options that are non-opioid, granted to a more limited availability in EMS. Tylenol, NSAIDs, Robaxin, Flexeril, lidocaine patches, blocks, and so on. When we are able to use things like the on q ball we see better pain management and our narcotic use drops substantially. I’ve had hip fractures where we don’t have to give any narcotics once the patient gets a fascia iliaca block for sometimes well over a day.

We just added toradol to the protocol, hasn’t been used much yet, no data to share..
 

Carlos Danger

Forum Deputy Chief
Premium Member
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If I break something I want to not feel it.
That's the attitude that a lot of people have, and it is actually a big problem. Physical pain is a normal part of the human experience and we should be able to deal with fair amount of it. The expectation of never having to tolerate any discomfort and catastrophizing about it and refusing to cope with it psychologically when it inevitably does happen is very self destructive - even if it doesn't ultimately lead to opioid addiction, which is of course the worst outcome and a shockingly likely one among patients who have the highest expectations for not experiencing pain. The medical community makes it worse by allowing patients to have unreasonable expectations and reinforcing the cognitive distortions that create further anxiety about pain and making it even more difficult for people to cope with. Then they throw opioids and anxiety meds at the the problem and everyone wonders what went wrong.

I’d be happy to help. Others here seem to be more the sit and watch you suffer for their own perverse enjoyment...
Yeah, you got me. All of us who see nuance and alternative management options where you aren't able to are just evil people. That follows logically, right?

Not (necessarily) taking a side here but doesn’t categorizing this as a BLS call effectively equal refusing to give pain meds?

Not refusing anything. Just acknowledging that the management that these types of injuries doesn't typically IV opioids.
 

FiremanMike

Just a dude
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That's the attitude that a lot of people have, and it is actually a big problem. Physical pain is a normal part of the human experience and we should be able to deal with fair amount of it. The expectation of never having to tolerate any discomfort and catastrophizing about it and refusing to cope with it psychologically when it inevitably does happen is very self destructive - even if it doesn't ultimately lead to opioid addiction, which is of course the worst outcome and a shockingly likely one among patients who have the highest expectations for not experiencing pain. The medical community makes it worse by allowing patients to have unreasonable expectations and reinforcing the cognitive distortions that create further anxiety about pain and making it even more difficult for people to cope with. Then they throw opioids and anxiety meds at the the problem and everyone wonders what went wrong.


Yeah, you got me. All of us who see nuance and alternative management options where you aren't able to are just evil people. That follows logically, right?



Not refusing anything. Just acknowledging that the management that these types of injuries doesn't typically IV opioids.

I wish I could like this twice.
 

DesertMedic66

Forum Troll
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That's the attitude that a lot of people have, and it is actually a big problem. Physical pain is a normal part of the human experience and we should be able to deal with fair amount of it. The expectation of never having to tolerate any discomfort and catastrophizing about it and refusing to cope with it psychologically when it inevitably does happen is very self destructive - even if it doesn't ultimately lead to opioid addiction, which is of course the worst outcome and a shockingly likely one among patients who have the highest expectations for not experiencing pain. The medical community makes it worse by allowing patients to have unreasonable expectations and reinforcing the cognitive distortions that create further anxiety about pain and making it even more difficult for people to cope with. Then they throw opioids and anxiety meds at the the problem and everyone wonders what went wrong.


Yeah, you got me. All of us who see nuance and alternative management options where you aren't able to are just evil people. That follows logically, right?



Not refusing anything. Just acknowledging that the management that these types of injuries doesn't typically IV opioids.
But to what extent is physical pain part of the normal experience? Should we no longer be giving pain medications at all because all pain is part of the human experience? Saying “hey man, I know you’re in a lot of pain because your leg was just amputated but you’re human and pain is good for you” doesn’t sit right by me. Patients experience pain differently and have different pain tolerances. A fractured arm on patient A may have no to minimal pain while on patient B it may be the most painful experience they have had.

We all live with the daily aches and pains but, I’m fairly sure, no one is suggesting that we treat those with pain medications. Your post makes it seem as if you believe any provider who treats any form of pain is doing a disservice to their patient.
 

FiremanMike

Just a dude
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But to what extent is physical pain part of the normal experience? Should we no longer be giving pain medications at all because all pain is part of the human experience? Saying “hey man, I know you’re in a lot of pain because your leg was just amputated but you’re human and pain is good for you” doesn’t sit right by me. Patients experience pain differently and have different pain tolerances. A fractured arm on patient A may have no to minimal pain while on patient B it may be the most painful experience they have had.

We all live with the daily aches and pains but, I’m fairly sure, no one is suggesting that we treat those with pain medications. Your post makes it seem as if you believe any provider who treats any form of pain is doing a disservice to their patient.
We can all differentiate patients who can tolerate pain versus patients who aren’t. We can usually tell those who are exaggerating their pain as well, but not always.

Patients who are tolerating their pain don’t need to be pumped full of opium just for the sake of giving opium.

I’ll speak for me, some patients need pain control because their pain is notably intolerable to them.

There seems to be a disconnect with some on this thread that it’s either all or nothing. The truth is that it’s in the middle.
 

Carlos Danger

Forum Deputy Chief
Premium Member
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But to what extent is physical pain part of the normal experience? Should we no longer be giving pain medications at all because all pain is part of the human experience? Saying “hey man, I know you’re in a lot of pain because your leg was just amputated but you’re human and pain is good for you” doesn’t sit right by me. Patients experience pain differently and have different pain tolerances. A fractured arm on patient A may have no to minimal pain while on patient B it may be the most painful experience they have had.

We all live with the daily aches and pains but, I’m fairly sure, no one is suggesting that we treat those with pain medications. Your post makes it seem as if you believe any provider who treats any form of pain is doing a disservice to their patient.
I'm curious as to what exactly about my post it was that you interpreted as meaning that I don't think traumatic amputations should receive pain medicine, or that providing any form of pain management is doing a disservice? That follows what I actually wrote about as well as the nonsensical claim made earlier in this thread that some of us would "sit and watch you suffer for their own perverse enjoyment" just because we think fractures can generally be adequately managed with BLS interventions.

My comment was less about acute pain management in general and more about the attitude of "I want to not feel it". No one likes pain. Pain has no utility aside from signaling us that something is wrong, and severe acute or chronic pain that goes untreated can become a pathology of its own which contributes to a myriad of problems.

However, experiencing pain at times is normal and to be expected, and being unwilling or unable to cope with that to any degree is a maladaptive behavior and should not be encouraged, which is exactly what we do when we treat any degree of pain as an emergency and use the patient's subjective report of comfort as a primary metric for the quality of the care that we provide. Rewarding maladaptive behaviors with highly addictive drugs has predictable consequences, and it is known that an unusual degree of anxiety over pain is in itself a predictor for chronic pain syndromes and medication dependency.

Even though this is clearly more of an issue and consideration in other settings, I don't think that means EMS gets a free pass here. Do we want to at least try to be part of the solution to one of the most pressing problems in healthcare today ? Do we want a seat at the table? Do we want to be seen as clinicians? Then let's start acting like it and realizing that pain is very complex, psychology is a big part of the pain experience, and that pain management can and should and at least sometimes consist of more than just slamming doses of the same drugs that are closely related to a massive problem with chronic pain, record numbers of addictions, and that directly cause the deaths of more people these days than any other non-natural cause. But, as long as we can't appreciate nuance and can't discuss complex issues like this without ascribing evil motives and putting words in each other's mouths, I don't have much hope for our ability to do that.

Just to be clear, because apparently these disclaimers are necessary here: I do give opioids, I would give pain medicine to someone whose leg was amputated, and I do not get perverse enjoyment from watching people suffer. Yes, it is possible for those things to be true while at the same time believing that pain is rarely an emergency and opioids should not always be seen as the be all / end all of pain management.
 

hometownmedic5

Forum Asst. Chief
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Yeah, you got me. All of us who see nuance and alternative management options where you aren't able to are just evil people. That follows logically, right? [/QUOTE]

There are states that have very, very limited options. Toradol is great. I've given tons of it, but we only got it here two years ago. ASA/APAP for pain, that was last year and we still only have oral, which is about as useful for acute pain as your square breathing malarkey(contextually). Fent was 6 or 8 years ago. Bottom line is it has only been within the last decade that our pain protocol filled in any of the gap between ice pack and morphine; and there are plenty of states behind mine, still living with chem packs and morphine. Your ED, fully stocked with every option and help, not endless help but help, is a poor frame of reference to being alone in the box with somebody whose been injured, bouncing and rocking around. Maybe it's hot out. Maybe it's really hot. Maybe it's cold. Maybe it's really cold. Maybe the driver is driving like a donkey and the ops radio won't shut up and the drivers side dually has a hung caliper that's squeaking like mad. Go ahead and offer me your ice pack and square breathing BS in that context.

I've acknowledged that snowing every patient into next Tuesday is wrong; and you've acknowledged that there are patients who require narcotic analgesia; so we've established that there is a middle ground between our positions. I have reached the limit of the aggregate loss of seconds while we ****er about where the line is, so I'm checking out.

If you(communal) give everybody you can a sedating dose of fentanyl just because you can or you're bored or annoyed, you should probably stop.
If you don't give anybody narcotics because you're too lazy, you're a waste of oxygen and I hope you die and long and painful death without analgesia.
Where you draw your own line is your own water to carry. Regardless of your specific belief structure, there's a force of some kind that's keeping track and will be along eventually to square up your account.

Seacrest, Out!
 

Peak

ED/Prehospital Registered Nurse
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ASA/APAP for pain, that was last year and we still only have oral, which is about as useful for acute pain as your square breathing malarkey(contextually).



 

Peak

ED/Prehospital Registered Nurse
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For those are going to argue that IV Tylenol is too expensive, the current average bulk price is $57 per 1 gram bottle, far cheaper than most people think and many other disposables we carry on the bus.

If cost is still a serious concern rectal works almost as well and is much cheaper. One gram of suppositories are about $1.50.

Comparatively fentanyl lollipops are about $20-260each depending on the dose and manufacturer. IV bulk dosing is in the realm of $2.50 per 100 MCG, but that does not account for the manpower used to account for the drug for the DEA requirements.
 
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