Pain Management
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It should be handled at both. The BLS level can offer Oxygen, emotional and reassuring support, along with offering a position of comfort. ALS can intervene with inhaled and injected sedatives, anaesthetics, and analgesics. All can be effective when dealing with patients in pain.
BossyCow
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One of the BLS ways of controlling pain is knowing when to call for ALS.
TheMowingMonk
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are you talking in the sense of administering drugs? cause i think it would be great if EMTs were allowed to give advil and tylenol, the simple over the counter stuff.
Epi-do
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I remember a time when ALS providers had to call in to the hospital and talk to a doc every time they wanted to give pain meds. The docs thought it was a pain in the rear, so we now have standing orders in our protocols.
On the one hand, it is a good thing. On the other hand - well, some are quick to go straight to the meds and not try other things first. When we had to call for orders, medics were alot better at utilizing non-pharmacological methods of controling pain. Splinting, positioning, and padding can do wonders to help with pain. Something else to keep in mind is that not all pain responds to pain meds in the same manner. While narcotics may be effective at altering your perception of pain related to musculoskeletal pain, it doesn't necessarily do a whole lot for belly pain.
As for basics being able to give "the simple over the counter stuff" - at one point I probably would have agreed with that. Not so much any more. Pharmacology is complex and I don't pretend to know even a fraction of the hows and whys of medication but, I have learned enough to know that there is no "simple" medication. Tylenol isn't as harmless as most people think. If you don't have a clue what it could potentially do to a patient, why it works in the manner that it does, and the indications and contraindications for administration, you have no business handing a medication out. (And Monk, I don't mean "you" as in you specifically, but in a more general sense.)
Ultimately, pain needs to be addressed on several levels. Sometimes a simple splint and a caring demeanor can be enough, other times patients really do need pharmocological interventions to assist with the pain. Often times, a combination of interventions is the most appropriate.
On the one hand, it is a good thing. On the other hand - well, some are quick to go straight to the meds and not try other things first. When we had to call for orders, medics were alot better at utilizing non-pharmacological methods of controling pain. Splinting, positioning, and padding can do wonders to help with pain. Something else to keep in mind is that not all pain responds to pain meds in the same manner. While narcotics may be effective at altering your perception of pain related to musculoskeletal pain, it doesn't necessarily do a whole lot for belly pain.
As for basics being able to give "the simple over the counter stuff" - at one point I probably would have agreed with that. Not so much any more. Pharmacology is complex and I don't pretend to know even a fraction of the hows and whys of medication but, I have learned enough to know that there is no "simple" medication. Tylenol isn't as harmless as most people think. If you don't have a clue what it could potentially do to a patient, why it works in the manner that it does, and the indications and contraindications for administration, you have no business handing a medication out. (And Monk, I don't mean "you" as in you specifically, but in a more general sense.)
Ultimately, pain needs to be addressed on several levels. Sometimes a simple splint and a caring demeanor can be enough, other times patients really do need pharmocological interventions to assist with the pain. Often times, a combination of interventions is the most appropriate.
TheMowingMonk
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i agree no drug is simple, even tylenol and advil. Both have their adverse effects. Tylenol is hard on the liver and Advil is hard on the kidneys. People due regularly die from tylenol overdoeses, it takes them a week to die from liver failure but it does happen. And im not just saying let just make it ok for EMT to be able to give the stuff, im just thinking add it into the EMT curriculum, teach us the effects and side effects of it. my point it that it is a week enough and well understood enough drug for EMTs to learn how to use it appropriately
Ridryder911
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So WRONG! Don't even know where to start. Oh, here where it can.. want to give med.'s go to school and get your Paramedic. Period.
R/r 911
Problems I foresee with this sort of thing:
1- If a patient really needs pain control, what type of pill would a B give that would be effective and take effect faster than treating with diesel and letting the nearest ALS or doc give em a shot.
2- the ubiquitous otc meds are so well known, chances are, the patient will have taken the drugs before calling you.
3- as to being weak drugs, there are recorded cases (too busy to ref them at this moment) of chronic etoh'ers going paws up with 3 tylenol.
to me, pain management at the Basic level is not about giving meds...
that was not my intention for starting that thread...
i would like to know if ALS feels they treat pain aggressively enough with meds...
but at the basic level, i was looking for non-med approaches, one of which, is calling for ALS when a pt is in a great deal of pain...
that was not my intention for starting that thread...
i would like to know if ALS feels they treat pain aggressively enough with meds...
but at the basic level, i was looking for non-med approaches, one of which, is calling for ALS when a pt is in a great deal of pain...
enjoynz
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We, at a basic level can give our patients Entonox (Nitrous Oxide).
It is a very safe and effect analgesic, with only a few contraindications.
I have had a talk with quite a few EMT's in the past, and know you do not use it in the States anymore. For one reason, because it was being used by the EMT's for themselves. Which in itself is very sad, as the patients miss out.
We use it in many cases, and it's a great. The patient self-administers the gas as they need it. If they do need a strong pain relief, Entonox can be given until the ALS can get to us (or us to them).
We can also give Paracetamol for mild to moderate pain relief, which is an oral drug.
I don't know why your EMT-B level can not give this form of pain relief.
You don't have to be a rocket scientist (or Paramedic) to learn a few contraindications and have a basic understanding of how these forms of pain relief work. But we don't get the pants sued off us like you do over there, if somthing does go wrong!
Cheers Enjoynz
It is a very safe and effect analgesic, with only a few contraindications.
I have had a talk with quite a few EMT's in the past, and know you do not use it in the States anymore. For one reason, because it was being used by the EMT's for themselves. Which in itself is very sad, as the patients miss out.
We use it in many cases, and it's a great. The patient self-administers the gas as they need it. If they do need a strong pain relief, Entonox can be given until the ALS can get to us (or us to them).
We can also give Paracetamol for mild to moderate pain relief, which is an oral drug.
I don't know why your EMT-B level can not give this form of pain relief.
You don't have to be a rocket scientist (or Paramedic) to learn a few contraindications and have a basic understanding of how these forms of pain relief work. But we don't get the pants sued off us like you do over there, if somthing does go wrong!
Cheers Enjoynz
el Murpharino
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Alot more EMS regions are making pain management a priority in their protocols, and narcotic therapy is being tweaked for these such things. I do understand that other states and regions have more progressive standards than some of us in NY, but recently fentanyl has been added, along with morphine as standing orders - but the instances we can use them are pretty limited (obvious fractures or deformity to limbs, at the present moment). It's not only EMS that is making a move toward pain management - hospitals too are making pain relief a main priority. I can definitely see more strides made in the near future. As far as BLS providers are concerned...there are far too many risks involved with narcotics from the side effects to allow them to be given at that level.
Much pain can be alleviated by BLS measures before ALS interventions. How many paramedics have gone straight to Morphine for a fracture before making sure the affected part was properly padded, splinted, elevated, padded some more in the ambulance, and iced? More than one, I assure you. BLS before ALS is good!
Again, I prefer Fentanyl over MS for simple skeletal stuff. However, to answer your question, I do go for the drugs first and honestly if I ever break my arm / leg, I would expect the same thing before you go and start manipulating it around. I drug 'em, reduce their pain, then splint it. Absolutely nothing wrong with doing so...........................
if i understand it right, kind of the dentist analogy...
you don't "drill the tooth, and then give novacaine for the pain"...
it makes you realize how limited BLS is for pain management...
Flight: If I had Fentanyl I'd prefer it over MS, too. And both of you are right, it certainly pays to medicate before any drastic fracture movement. I was thinking mostly of uncomplicated fx that didn't need anything spectacular, and we too often forget the basic stuff (that was actually my ill stated point). Still, though, I don't think we do enough pain management in the field. Personally, I try to administer the first dose of MS while the other part of the crew is assembling the traction splint. Makes everybody happy that way!
Ridryder911
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Nothing personal Doug, but I am shocked a Paramedic would even state such.
I would hope they would deliver Morphine or some form of analgesics; that is if they are even half arse good. Why would anyone want to inflect pain? Ask any physician if they rather sedate before splinting or even anesthetize before suturing? Like asdescribed the Dentist should do before filling. Splinting is way over taught. Seriously, teach the usual sugar tong method, etc. and pad all areas and especially the joints, that is good enough to get to the ED.
Nope not really, little to none. Hence the reason all EMS units should be ALS. Let me fracture your arm, you choose which you would rather have. Cold pack and splints or analgesics then the usual splint and cold packs?
I would hope they would deliver Morphine or some form of analgesics; that is if they are even half arse good. Why would anyone want to inflect pain? Ask any physician if they rather sedate before splinting or even anesthetize before suturing? Like asdescribed the Dentist should do before filling. Splinting is way over taught. Seriously, teach the usual sugar tong method, etc. and pad all areas and especially the joints, that is good enough to get to the ED.
No such thing as BLS or ALS, rather just patient care. We only teach this because only in EMS we allow providers just to perform BLS and actually call it treatment, in the real world BLS would be called first-aid. This is part of the problem that only occurs in EMS. The .."BLS before ALS bullfeces line. Part of the wonderful myths of EMS, similar to same old line of.." EMT saves Paramedics line.. Hopefully someday with some education we can eradicate this type of limericks, that is nothing more to hype egos and make ones feel that they are special.
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I really don't know what your basics are taught down there, but up here, our BLS crews can perform a helluva lot more than just your average first aider. Now i agree with you, ALS is more beneficial over the BLS, but sometimes that just can't happen (due to funding, politics, etc.) All agreed though, pain meds would be great before any manipulation..(i know i'd want it, and that's what my patients get) Just my 2 cents.
TheMowingMonk
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Well the idea of only having ALS is a good idea. The problem with that is its not plausable for the EMS training system we have now. I Know im going to go ALS as soon as I can. But the key for ALS is you have to do BLS first. You have to be an EMT before you can be a paramedic. So there has to be a place for BLS or our training system would have to change to make it purely ALS
Ridryder911
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Unfortunately most U.S. basic EMT courses are 120-150 hour clinical time can range from none to a few hours (<50 hours); the curriculum is just a little more than the ARC Advanced first-aid course. Heck, read the posts where the discussion of a Paramedic course is 6 months to 20 months long. Even beauticians that cuts hair goes longer than that... Do we not see a problem?
Your entry level course is much more. Even then with that said, I realize not every EMS will ever be ALS (albeit very few) but many services here want to remain as BLS; not that they have to. This is what is the shame. Many assume that they cannot afford not to but can afford other luxuries in the city such as swimming pools, tennis courts even a FT FD, etc. It is all in the priorities and commitment made by the community and especially recommendations made by the local EMS.
Now who said " You have to do BLS before ALS?" and one has to be a Basic before Paramedic? Again another EMS myth!
Does it really matter, if I place the patient onto a LSB before I start an IV if there is an obvious fractured hip and I give an analgesic prior?. Or if the patient has agonal respirations, should I have to await a blood pressure before intubating them? Why? Is the blood pressure number going to change my treatment or the patients respiratory status? C'mon the BLS and ALS differential is B.S.! Patient care is patient care ! Whenever we start teaching medical care (alike the rest of the health professions) and NOT attempting to separate or divide them; then and only then, there will be less confusion of patient care.
Most of the assessment and treatments are or should be done simultaneously or concurrently, in real life it is NOT or should NOT be alike a NREMT testing station. Even NREMT assume that one would develop a continuum and understanding of having the ability to perform multi tasking and having a knowledge between testing procedures and real life. That patient care is NOT always a step by step process before proceeding to another step. It is taught to evaluate that you can assess each area and perform a thorough examination. Do you check for distal pulses in someone with a blood pressure of <50mm/hg? If you do what do you expect to find? Then why did you check it?
As far as being an EMT first, not all areas will require you have to do that. I was a working Paramedic before I even took an EMT course. So that theory is out the window. I as well work and teach with many that never worked as an EMT first and they are excellent Paramedics with no difficulties. Many are finding out that they are actually better with no bad habits to break. Alike nursing, RT's, physicians, etc. we too should not have to work upwards in the profession first. Remember multiple levels were always made in comparison of the gold standard and usually as an excuse for not being able to deliver it.
Myself and other educators are attempting to remove many of these so called "myths". Many of these so called "wives tale" that are taught or discussed are not validated per science or even common reason. It is usually taught because .."this is the way, it has always been" method.. again, not based upon facts. Alike patient care, we must be able to justify upon why and how we do things, not just the "because" method. Step outside the box...
R/r 911
well, i am a basic, and i agree with Rid... if a patient has anything going on requiring a monitor, or advanced intervention, or severe pain for that matter, can i provide what they need? no i can not...
it is not BLS or ALS... it is one continuum of patient care...
ALS means all the skills and knowledge from BLS to Medic...
BLS means the learning stops far short along the way..
it is not Basic before medic... a medic by definition is already competent in basic skills as part of the "whole package"..
in a system with limited resources, a basic can be valuable in aiding the medic... doing the redundant skills that a medic would do, but that a basic could also do, freeing up the medic for higher level skills...
if viewed in this way, it is all about resources...
if a system could have dual medics, they should...
when a system can't, then have a medic assisted by a qualified basic...
when a system is really strapped for resources, and must staff basics, better have good basics, who's best skill maybe knowing when to get ALS on board ASAP...
that basically is the structure we have now...
not a knock on basics, because i am one, but just the reality.