how much pain?

[Veneficus]

So...

I know pain control in the prehospital environment gets a lot of press time here, but after reading a post yesterday, I figured I would post a poll.

It is ok to comment too.

 

[VFlutter]

John Snow....

No patient should be left in pain unnecessarily. If I had a choice, i would even go as far as local anesthetic for IV insertions. If you can prevent an unpleasant side effect such as pain, why wouldn't you? (excluding medical reasons)

 

[Epi-do]

I admit I could probably be a little bit more liberal in deciding to initially give it, but once I make the decision, I tend to let it flow pretty freely.

 

[DrParasite]

by pain control, do you mean control it with pain meds, narcotic pain meds, ice/positioning/splinting, or some other means?

 

[lightsandsirens5]

I don't see, in today's day and age, why all patients should not arrive at the ER pain free or as near to that as possible. I think the only major exception is when the pain response is the only thing keeping their pressures up.

 

[Camtheman]

What about when pain is an aid in the diagnoses?

 

[Aidey]

What about when pain is an aid in the diagnoses?

Such as?

 

[usalsfyre]

What about when pain is an aid in the diagnoses?

This is generally a myth.

 

[Camtheman]

I was always told that it was unwise to give pain managment to undiagnosed abdominal pain.

 

[Aidey]

Bzzzzzzzzzzzzzzzzzzzzzzzzzt.

Wrong answer.

 

[nocoderob]

I am generally in between the last two. Minimal to 0 pain, no drooling

 

[Aidey]

I picked "I treat pain but leave the patient in some reported pain." because it was the closest to what happens in reality, although "sometimes" should be added to the end.

Years ago I heard a nurse ask a very good question, "What level of pain is acceptable to you?". For some people it is none, for others it is 5. I am liberal with fentanyl, our only pain medication, but I also am not allowed to give doses that are too big, or too close together. If I were to snow everyone, or get everyone down to a 0 we would be sitting on scene for a long time. It is generally much easier to get someone down to their acceptable level, initiate transport, and give maintenance doses en route. If possible I also like to dose immediately before unloading the patient so it is less likely the fent will wear off before the doc gets around to writing a new order. I'm not leaving the patient with some pain because I'm stingy or don't think they deserve pain meds, it is just a compromise between stupid long scene times and getting the patient to the hospital without too much discomfort.

I recently had to give a broken hip 250mcg of fent, the max I could give her based on her weight, and she was still screaming at the top of her lungs. I would not have gotten orders for more based on our transport time (under 10 mins) and I'm not allowed to mix opiates and benzos. I'm anticipating a phone call once QA/QI gets a hold of that chart because of how I dosed her.

So, while I like to minimize pain as much as possible, I know that it is impossible to make everyone a 0 with what I have to work with.

 

[usalsfyre]

I was always told that it was unwise to give pain managment to undiagnosed abdominal pain.

Its an old, persistent wife's tale that comes from the early days of surgery (Halstead maybe?). The prevailing opinion was that the "trained hands of a surgeon" must assess an abdomen before opiates were administered. Undifferentiated abdominal pain is probably going to get scanned anyway now a days, plus there has been at least of bit of published research that showed no difference in diagnostic accuracy.

 

[EpiEMS]

plus there has been at least of bit of published research that showed no difference in diagnostic accuracy.

Thank g-d for evidence based medicine.

This reminded me: maybe we could even consider IM morphine at the BLS level. Or fentanyl "lollipops" (ActiQ, I believe it's called). It's been used in the military for years for trauma, so why not in civy EMS?

 

[Veneficus]

Its an old, persistent wife's tale that comes from the early days of surgery (Halstead maybe?). The prevailing opinion was that the "trained hands of a surgeon" must assess an abdomen before opiates were administered. Undifferentiated abdominal pain is probably going to get scanned anyway now a days, plus there has been at least of bit of published research that showed no difference in diagnostic accuracy.

To add to this, there is evidence that treating abd pain actually helps for diagnosing.

I have seen some old school surgeons actually leave a gunshot patient in pain to see if the pain increases supposedly from irritating the peritomeum as a diagnostic indicator, but the same surgeons as you said, CT the patient before the final decision for surgery anyway(which in 2 cases was not to operate despite increasing pain), so I think it is more of an old habit of their training than an actually part of their decision tree.

 

[Shishkabob]

People here know I'm an advocate of analgesia. I'm basically akin to Aidey in how I do it.

My rule of thumb is to cut the pain atleast in half, (IE from a 10 to a 5). Once I cut it in half, I lay back in the amount I give and re-assess before moving on. If they were tearing from pain before, but now are smiling at a 3/10, I'm probably set for a bit. Fact is, there are some people where you can't get rid of all the pain, and others that the only way to do that is to completely knock them out, which causes more issues to deal with. If it comes down to it, I do conscious sedation so they forget all about it. Some people will report pain no matter the amount of analgesia given. I'm not going to give another 100mcg of Fentanyl just because they report a 2/10.



Because of it being situational dependent, there is no best choice for me to choose.

 

[NYMedic828]

People here know I'm an advocate of analgesia. I'm basically akin to Aidey in how I do it.

I'm the third vote for the "leave some there" in conjunction with you and aidey.

I usually ask the patient how they are doing and if they feel the medication helped them and if they honestly want more of it. Many patients will tell me their pain is down to a 4 from an 8, but they don't necessarily want to be medicated if they can tolerate. The only real pain management I ever do is alleviating chest pain through NTG administration, but i think the general concept remains the same.


Unfortunately, and as much as I hate to say it, in the last 8 months (this year basically) i have cracked the seal off of ONE vial of morphine. I have never broken open a fentanyl.

This is not how I prefer to do things but sadly its become taboo to assume a patient has true pain in NYC and as such the suggestion to my partners, whom are my superior in experience/knowledge (or supposed to be anyway) is essentially worthless. I guess in part this is due to the fact that 90% of our assignments are wellfare patient based people who depend on EMS to carry their lives. Kind of kills a lot of morale of people wanting to really help them.

 

[Veneficus]

I guess in part this is due to the fact that 90% of our assignments are wellfare patient based people who depend on EMS to carry their lives. Kind of kills a lot of morale of people wanting to really help them.

That is medicine pretty much everywhere.

The poor, even if they became so from their own choices, is and will always be a majority of patients.

It is unfortunate many providers think they are there to help the "honest average people" because those people are largely healthy, they don't need help, and certainly are not regularly trauma patients.

We are not here to judge, we are here to help.

 

[fast65]

I'm on the same side of the ball as a lot of you, I'm a large proponent of pain management. As such, I have been affectionately deemed "The Candy Man" by my coworkers.

Typically, I'll let my patients know that I'm going to do my best to help with their pain, but that I may not be able to take it away completely. With that, I'll ask what is a tolerable level of pain for them, and that's the point I shoot for.

Fortunately for me, I have no maximum dose for narcotics, I am simply allowed to "titrate to desired effect". However, at a certain point, I am required to send a copy of the chart to my medical director for him to review.

 

[usalsfyre]

With that, I'll ask what is a tolerable level of pain for them, and that's the point I shoot for.

Exactly the way I approach pain management. The problem with "John Snow" is it can slow down care, not because of problems with diagnostics, simply because it's a bit difficult to obtain a history when the patient is drooling on their shirt...

I REALLY like benzos and opiates is conjunction.