factors that affect pain treatment in pre-hospital setting

AshWredberg

AshWredberg

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Doing a research project and wondering what certain factors, if any, will determine treatment of pain in a pre-hospital setting? Any thoughts or comments would be greatly appreciated!
 
How much of a pain it is to restock drugs. How close to shift change. The culture at the department. How the medic is QI'd for narc administration. The patient's socio-economic status. How often the paramedic has seen this patient. The patient's complaint. The patient's vital signs. If the medic's "bs detector" is going off. The paramedics mood. The day of the week. I mean, there's a zillion reasons... None of them really valid. If the patient is in pain, we should treat it. We often don't.
 
My options include:
oral paracetamol (yup, "tylenol"),oral buprofen (yup, "ibuprofen") IV paracetamol, inhalation methyoxyflurane (penthrox), fentanyl, ketamine, midazolam (not a pain med per se, but can potentiate analgesics and take the hysterics out of it as well as give a little amnestic to event effect). Not ignoring simple things - ice pack, traction splint/ reduction, etc...

As DE said, a lot... including a military bias of "do they look to be in pain," "my ketamine is in a huuuuuuuuuuuge MVD and for me to draw up and handle a teeny wittle dose is a pain in the butt", the sun, the moon, the tides, presence or absence of lunch, frequent caller/ "abuser," the mechanism of injury or illness, presence or tendency of shock, altered mental status / level of consciousness, presence of heavy track marks (and the ability to get an IV...), respiratory drive, age (we have age limits on penthrox, fentanyl,...), medical history, known renal or hepatic impairment/disease, how much of an attitude the ER has, number of patients,...

Not exactly a one size fits all answer. Little pain gets little meds. Big pain probably gets big meds, buuuut if I'm worried about hemodynamic instability, respiratory drive and this rapidly turning to RSI...

As he said, it's part of the overall care, but is one aspect of patient management. But if they're hurting they should get something. Titrating that to what is most appropriate in a field expedient setting can be more tricky.
 
Sorry I should have been more thorough, we are basing it off an abstract with factors such as distance to hospital, gender, age, extent of injury, length of time to hospital etc
 
AshWredberg said:
Sorry I should have been more thorough, we are basing it off an abstract with factors such as distance to hospital, gender, age, extent of injury, length of time to hospital etc
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There's waaaaay more to it than that. But, you'll see when you're out of school and working. It's never that simple.

Offer people in pain some meds. If they don't want it, they don't get it. Treat pain if you can.
 
I just want to add that there is more to pain management than drugs. Position of comfort and proper splinting techniques go alomg way for pain management, lots of times reducing the need for medications.
 
Distance to hospital can affect it assuredly.. however, that also has to take into consideration extent of injury/ life threat/ stability also. IV paracetamol isn't going to be as likely then for the infusion time (and let's face it, the ER immediately DCs it and throws it out.)

Don't really care if it's a boy, girl, or whatever variation in between.

Age, I can't do penthrox for kids and it is liver toxic so no CRI patients and limited for diabetes as well. My fentanyl cuts off low also. Ketamine is... cautious. Again, , especially with comorbid factors (renal failure, hepatitis, known or presumed liver disease), the penthrox becomes cautious and some drug dosages halve. Are we pushing respiratory depression,...

Little pain gets little meds.

Big pain gets bigger.

Contraindications exist and prehospital is usually a limited number of options.

BLS before ALS. As TX just pointed out, splinting (including reduction and traction)

Aaaand it's 0614am here after a night shift... Ya'll have fun :)
 
NYBLS said:
Its pretty simple: Are they in pain? Yes-treat it. No-don't treat it. Everything else is judging.
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That's pretty much my exact protocol. Abs i use the hell out of it

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BrandonEMS said:
if the pt takes Vivitrol that's going to have a affect.
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That's where good clinical judgement comes into play. Both naltrexone and suboxone are red flags and maybe a sign you should ise toradol or ketamine for pain mgmt instead

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AshWredberg said:
Sorry I should have been more thorough, we are basing it off an abstract with factors such as distance to hospital, gender, age, extent of injury, length of time to hospital etc
Click to expand...

Don't forget about:
1) Bystanders
2) Ethnicity
3) cultural background
4) prior injuries
5) psychological state
 
DEmedic said:
Offer people in pain some meds. If they don't want it, they don't get it. Treat pain if you can.
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Next time I am in Delaware visiting my sister, I am going to call DEmedic's 911 agency for a splinter, and expect to get morphine and fentanyl. my pain is no less real than anyone elses.
 
DrParasite said:
Next time I am in Delaware visiting my sister, I am going to call DEmedic's 911 agency for a splinter, and expect to get morphine and fentanyl. my pain is no less real than anyone elses.
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You would be downgraded to BLS and a medic would never see you, unless the splinter was a 2x4 and it was driven through your torso.

...and allow me to share:

Simple Definition of obtuse
  • : stupid or unintelligent : not able to think clearly or to understand what is obvious or simple
    a : lacking sharpness or quickness of sensibility or intellect : insensitive, stupid

It seems like the shoe fits.
 
DrParasite said:
Next time I am in Delaware visiting my sister, I am going to call DEmedic's 911 agency for a splinter, and expect to get morphine and fentanyl. my pain is no less real than anyone elses.
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Ok. Have fun with your ALS bill.
 
If they are a cancer patient in pain… They get whatever they want


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DEmedic said:
No ALS bill in DE. It's a county funded service.
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How unfortunate.

I'll happily treat pain. The financial impact is something to possibly consider though.
 
I agree if pn, treat it; I see so many medics who don't. Of course always follow instincts for the BS.
 
Also, I have a personal rule that I believe people the first time I meet them; Just cuz I give pain meds one time doesn't mean I will every time.


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