factors that affect pain treatment in pre-hospital setting

[dutemplar]

Yea, rapid downgrade to alpha and "give Panadol or buprofen for pain" on the splinter. Actually, I wouldn't even be downgraded... CCP would never be dispatched for a splinter unless there was reported serious bleeding or the splinter was the size of a 2x4 or larger. Sitting in as the Clinical Team Leader in the command center and coordinating 80 ambulances and 10CCPs tonight for the country, that would be fast instructions of "No CCP, Priority 2 to See and Treat, Panadol or Buprofen for pain."

Ca, yeah.. usually going to start heavier. IV paracetamol is great stuff, and methyoxyflurane is pretty cool too.

...fully funded service. No bills of any kind.

 

[DesertMedic66]

If I have a patient who states they are in pain but are showing no signs of actually being in pain they will not get pain meds from me. I'm not stingy with meds however if you tell me you say your pain is 10/10 and you are relaxing, falling asleep on the gurney, and are on your phone during my time with you, you will not be getting meds from me and probably not from the hospital.

For trauma it completely depends on the injury. A stubbed toe will not be getting pain meds. A possible fracture will (if the patient wants pain meds).

 

[StCEMT]

distance to hospital: For me, I am close to a lot of hospitals. Not so close I can't treat, but there have been times I am literally that close I would finish an IV by the time we pull in. Not typically the case though.
gender: Gotta refresh on that one haha
age: Real young/old get softer doses, most adults will just get a normal adult dose
extent of injury: Bad boo boo= mo betta meds
length of time to hospital: Basically same as the 1st.

Then there are the other methods mentioned. I have on multiple occasions used positioning to relieve pain and it can make a significant difference. Ice packs are always nearby. Don't let people mess with injuries (ex. rubbing their eyes when they got meth in their eye).

 

[RocketMedic]

Depends on the story- if it's a legitimately-painful episode, I'll work as hard as I can to palliate it.

I was counseled and thought of openly, negatively, by administration and coworkers at EMSA as "the candyman", because I had a reputation for medicating patients who were in pain. It worked out to be about 8% overall of the people I'd see in any given month on average. I was one of the only medics that would medicate abdominal pain at the time in Western Division. Plenty of them didn't even know it could be done.

There's multiple levels to your question. Let me break them down:

1. Medical: Is there a medical reason to medicate this pain? As TXMed said, many injuries can actually be palliated quite effectively with the rarely-practiced art of good positioning, cooling and even psychological measures like distraction. The pediatric femur fracture we took the other day needed no medication because he literally forgot about it when we tucked him into his carseat and let Mommy ride with him in the back- babies in pain don't generally babble and laugh. Same goes for things like scrapes and minor burns- cryrotherapy is a great option. Ask what the problem is and remove thorns, small pieces of glass and gravel, etc. One of the dumbest EMTs I've ever met insisted that protocols forbade us from removing glass from a superficial hand laceration and reported me to the admin for pulling a shard out of a finger...but it was the right thing to do.

Then there's considerations of pharm: route, authorized and anticipated-necessary dosages, allergies and sensitivities, comorbidities, etc. The medical goo that we deal with. One of the biggest considerations is if our meds will even be effective in the dosages we are allowed. For example. a medic working in a system that requires him to give 0.25mcg/kg of fentanyl q10 for "acute pain" with a cap of 100mcg and who has a 100kg patient with an open tib/fib does legitimately have a claim that their therapy is not anticipated to be effective at all. There are then considerations of hospital follow-on, etc.

2. Operational: Does this make sense to take care of in the truck?

3. Cultural: This is the big variable. Plenty of places and medics have conservative opinions of pain management or outright don't view it as a normal part of their job, use it as a weapon against "********" patients, or simply don't care enough to use it. Others have hyperconservative practices (think the people who BLS in hip fractures because they don't want to risk missing an IV). Others are lazy and make their partners tech most calls. Others don't see a need for it in patients with "minor" causes of pain, like isolated fractures. Fear is a big one- fear of adverse effect, fear of opinion and fear of administration (a side effect of nailing the most aggressive medics to the wall as examples of what not to do). Most of these traits are actually cultivated in larger organizations (the "high-performance systems" in order to keep narcotics use and restock down and limit the chances of a paramedic overdoing something. From the managerial perspective, it's better that a thousand patients get temporarily undertreated than it is for one person to suffer an injury attributable to the agency's actions, and that leads to active official and unofficial cultivation and enforcements of very arbitrary standards. For example, when I was at EMSA, it was a point of pride between most of the medics I worked with that they didn't open their narc boxes on a 12-hour. People like me who did were openly derided. Few people like being derided by their coworkers, especially when those coworkers are seemingly respected by one another and the organization more than you.

Culture is easily the hardest nut to crack. A lot of the above people are actually really capable providers, adequate at the routine and good, even stellar, in the clutch. It's really hard to get rid of that attitude, though, so you might find that a paramedic who is a rock star with intubation and STEMI detection and skills and even has good people skills may not believe in pain management and rarely, if ever uses it. It's a huge challenge that has a massive impact on patient care but is mostly unknown, and I doubt it stops in the ambulance either.

 

[NYBLS]

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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Yes, because people can't certainly ever have multiple episodes of pain...

If I have a patient who states they are in pain but are showing no signs of actually being in pain they will not get pain meds from me. I'm not stingy with meds however if you tell me you say your pain is 10/10 and you are relaxing, falling asleep on the gurney, and are on your phone during my time with you, you will not be getting meds from me and probably not from the hospital.

For trauma it completely depends on the injury. A stubbed toe will not be getting pain meds. A possible fracture will (if the patient wants pain meds).

I'm assuming you also think vital signs are a good indicator for pain...

 

[STXmedic]

I'm assuming you also think vital signs are a good indicator for pain...

I'm pretty damn liberal with pain meds, but there's some common sense and clinical judgement that goes into medicine too. You know, not just "see this, do that" cookbook medicine how you described earlier. Every chest pain doesn't get nitro. Every asthmatic doesn't get Mag. And every utterance of the word "Ow" doesn't get fentanyl. Pain medicine is not the only way to treat pain, nor is treating every little booboo necessary or indicated.

 

[Handsome Robb]

I'm assuming you also think vital signs are a good indicator for pain...

I have a pretty low threshold for treating pain but I agree. If you tell me your pain is 10/10 then proceed to laugh and joke or sleep with no outward physiological or emotional signs of pain I'm probably not going to be giving anything to you. I work in a double medic system so whether I give it or not doesn't determine if it's my call or not.

With that said most people that tell me they're in pain and want something for it will get it unless I've got a reasonable reason not to.


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[NYBLS]

I'm pretty damn liberal with pain meds, but there's some common sense and clinical judgement that goes into medicine too. You know, not just "see this, do that" cookbook medicine how you described earlier. Every chest pain doesn't get nitro. Every asthmatic doesn't get Mag. And every utterance of the word "Ow" doesn't get fentanyl. Pain medicine is not the only way to treat pain, nor is treating every little booboo necessary or indicated.

It sounds as if you are assuming pain medicine includes only giving narcotics? Ice is a form of pain relief. Where did I describe cook book medicine? I think if someone is in pain then treating that pain is our job similar to how treating a pt with symptomatic hypotension is, would you consider that "cookbook medicine"?

 

[VentMonkey]

I ask them to flip a coin...

Thinken' iz purrtty hard...

 

[VentMonkey]

It sounds as if you are assuming pain medicine includes only giving narcotics? Ice is a form of pain relief. Where did I describe cook book medicine? I think if someone is in pain then treating that pain is our job similar to how treating a pt with symptomatic hypotension is, would you consider that "cookbook medicine"?

Not for nothing, but that isn't what I took away from STXmedic's post at all. It sounded to me as though he was implying he likes to use sound clinical judgement with each and every patient (completely logical, and understandable), but perhaps he'll chime in and further elaborate, cheers!

 

[STXmedic]

It sounds as if you are assuming pain medicine includes only giving narcotics? Ice is a form of pain relief. Where did I describe cook book medicine? I think if someone is in pain then treating that pain is our job similar to how treating a pt with symptomatic hypotension is, would you consider that "cookbook medicine"?

I thought this was more recent, apparently it was a couple weeks ago, but regardless:

e: Are they in pain? Yes-treat it. No-don't treat it. Everything else is judging.

This, to me, is what sounded cookbook. See this, do that, no exceptions.

Since you failed to specify what falls inside your idea of treating pain, and these conversations tend to always go that direction, I assumed you meant pharmacological treatments. If that's not what you meant, then we're in agreement- Ice, positions of comfort, and laughter should all fall in the continuum of treating pain, along with pharmacological means.

 

[DesertMedic66]

Yes, because people can't certainly ever have multiple episodes of pain...



I'm assuming you also think vital signs are a good indicator for pain...

No where in my post did I ever state anything about vitals reflecting pain status.

 

[EpiEMS]

How do folks feel about BLS providers refusing to BLS a patient if they think pain control might be indicated?
I have asked for an ALS transport when I noted that my BLS airway measures weren't working -- so would there be anything wrong with asking for an ALS assist for an uncomplicated, acutely painful extremity fracture (after splinting and ice pack use), when I have no pharmacololgical means of reducing pain?

 

[NomadicMedic]

How do folks feel about BLS providers refusing to BLS a patient if they think pain control might be indicated?
I have asked for an ALS transport when I noted that my BLS airway measures weren't working -- so would there be anything wrong with asking for an ALS assist for an uncomplicated, acutely painful extremity fracture (after splinting and ice pack use), when I have no pharmacololgical means of reducing pain?

That depends if it's warranted. I've found that BLS requesting ALS for pain management is 90% BS. Especially if the patient is loaded in the truck and the BLS crew waits on scene for the medic and the narcs to show up. In the past I've had several BLS crews request an ALS intercept for pain management and then had the patient tell me they didn’t want any drugs!


If BLS gets on scene and finds a patient in pain that they can’t move without more pain, I’m more than happy to help with that.

 

[VentMonkey]

To add to DE's remarks, am I reasonably closer to you than the ED?

Also, every EMT is different, and turn around may yield rather green EMT's who lack the proper assessment skills, but to answer your question in short, it's seems otherwise sensible and humane, yes.

 

[EpiEMS]

That depends if it's warranted. I've found that BLS requesting ALS for pain management is 90% BS. Especially if the patient is loaded in the truck and the BLS crew waits on scene for the medic and the narcs to show up. In the past I've had several BLS crews request an ALS intercept for pain management and then had the patient tell me they didn’t want any drugs!

If BLS gets on scene and finds a patient in pain that they can’t move without more pain, I’m more than happy to help with that.

I certainly am loathe to move certain patients -- say, a hip fracture who's otherwise stable but going to be difficult to move without good pain control. The problem I have is, I don't want to ask a patient if they would like pain control -- because I don't want to obligate the medic to provide it (especially because, in my system, they're limited to benzos and narcotics that many do not like to "bother" using -- if they had, ketorolac or something, I wouldn't be so coy).

To add to DE's remarks, am I reasonably closer to you than the ED?

Also, every EMT is different, and turn around may yield rather green EMT's who lack the proper assessment skills, but to answer your question in short, it's seems otherwise sensible and humane, yes.

Thanks for your reply -- my experience is that I usually have ALS <5 min from me, while the ED is circa 15min, but my ALS colleagues tend to be hesitant to use their pain control options (and some even hold to the old dogma of not medicating abdominal pain).

 

[VentMonkey]

I certainly am loathe to move certain patients -- say, a hip fracture who's otherwise stable but going to be difficult to move without good pain control. The problem I have is, I don't want to ask a patient if they would like pain control -- because I don't want to obligate the medic to provide it (especially because, in my system, they're limited to benzos and narcotics that many do not like to "bother" using -- if they had, ketorolac or something, I wouldn't be so coy).



Thanks for your reply -- my experience is that I usually have ALS <5 min from me, while the ED is circa 15min, but my ALS colleagues tend to be hesitant to use their pain control options (and some even hold to the old dogma of not medicating abdominal pain).

Sorry to hear that, it's is unfortunate that this mindset still exists in this day and age.

 

[EpiEMS]

Sorry to hear that, it's is unfortunate that this mindset still exists in this day and age.

Same mindset that keeps EMTs from being allowed glucometry

 

[VentMonkey]

Same mindset that keeps EMTs from being allowed glucometry

Or in my neck of the woods, CPAP, and Narcan, but at least our fire guys carry ASA now.

That is thee single most prehospital "life-saving" treatment one can render in the event of a true ACS/ AMI event, IMHO.

 

[EpiEMS]

Or in my neck of the woods, CPAP, and Narcan, but at least our fire guys carry ASA now.

That is thee single most prehospital "life-saving" treatment one can render in the event of a true ACS/ AMI event, IMHO.

No disagreement here. I'd take CPAP and/or albuterol over Narcan, though...