Inter-facility Considerations Nausea and Vomiting

zzyzx said:
Drugs are illegal. Im not going to facilitate someone obtaining a narcotic so they can get high.
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Are you able to tell with 100% accuracy if the patient is a seeker? Or do you withhold medications from a patient who is in pain because you think they may be a seeker?
 
zzyzx said:
Drugs are illegal. Im not going to facilitate someone obtaining a narcotic so they can get high.
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I'm also not going to withhold pain management from someone who is in pain. I'd rather medicate a hundred seekers than miss one person truly in pain. And most places I've worked have pushed aggressive pain management.
 
TransportJockey said:
I'm also not going to withhold pain management from someone who is in pain. I'd rather medicate a hundred seekers than miss one person truly in pain. And most places I've worked have pushed aggressive pain management.
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This. If I medicate a seeker it has zero effect on me. I don't pay for the meds. I don't get written up. All it requires me to do is just a little bit more paperwork and some very easy math.
 
DesertEMT66 said:
This. If I medicate a seeker it has zero effect on me. I don't pay for the meds. I don't get written up. All it requires me to do is just a little bit more paperwork and some very easy math.
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You sir, are single-handedly responsible for all the drug seekers coming back to us in the ER!

I'm kidding. But seriously, is that your attitude? That you just don't care? I'm sure you are a better paramedic than that.

No, I'm not ever 100% sure of anything, but when I have a patient, either in the ambulance or the ER, who I have seen 3 times in the last week for their "chronic pancreatitis," and they have been d/c each time with a normal lipase, and they are asking me for another shot of Dilaudid in between chatting away on their phone, then no, they will not be getting it from me. I think that is common sense, don't you?

I don't want to beat a dead horse, but statements like "paramedics have no business deciding you gets pain meds or who doesn't" is really a dumbing down of our jobs as paramedics.

Back to what I originally said about Benadryl pontentiating narcotis...sorry but I only have anecdotal evidence, but here it is right from the horse's mouth....

http://forum.opiophile.org/archive/index.php/t-2341.html
 
zzyzx said:
No, I'm not ever 100% sure of anything, but when I have a patient, either in the ambulance or the ER, who I have seen 3 times in the last week for their "chronic pancreatitis," and they have been d/c each time with a normal lipase, and they are asking me for another shot of Dilaudid in between chatting away on their phone, then no, they will not be getting it from me. I think that is common sense, don't you?
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If you know objectively that they are not experiencing an exacerbation, and you know for a fact that they are a drug seeker, then yeah, you might be justified.

But generally speaking, denying opioid analgesia because you think or suspect that someone is just looking for a high is very bad policy. It hurts real patients and does nothing to cure the disease of addiction or the seeking behavior.
 
zzyzx said:
You sir, are single-handedly responsible for all the drug seekers coming back to us in the ER!

I'm kidding. But seriously, is that your attitude? That you just don't care? I'm sure you are a better paramedic than that.

No, I'm not ever 100% sure of anything, but when I have a patient, either in the ambulance or the ER, who I have seen 3 times in the last week for their "chronic pancreatitis," and they have been d/c each time with a normal lipase, and they are asking me for another shot of Dilaudid in between chatting away on their phone, then no, they will not be getting it from me. I think that is common sense, don't you?

I don't want to beat a dead horse, but statements like "paramedics have no business deciding you gets pain meds or who doesn't" is really a dumbing down of our jobs as paramedics.

Back to what I originally said about Benadryl pontentiating narcotis...sorry but I only have anecdotal evidence, but here it is right from the horse's mouth....

http://forum.opiophile.org/archive/index.php/t-2341.html
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You may see that patient 3 times in one week in the ED and know their Dx. However I may only see that patient once. And that one time the patient may be in pain. How am I supposed to know how many times a patient has been seen in the ED in one week or what their Dx is?

I'm not talking about the patients who say they have 10/10 pain but are relaxing comfortably and talking on their phone.
 
I have a personal rule that the first time I meet you, I medicate. As I see you again and again, I may be more selective in my therapy.
 
zzyzx said:
Drugs are illegal. Im not going to facilitate someone obtaining a narcotic so they can get high.
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But it's not our job to determine who has legitimate pain and who doesn't. Treatment of pain is based on the patient's perception not our own. Pain is a subjective experience. I would rather give morphine to 10 drug seekers than miss one patient having legitimate pain. If they want to get a little buzz off the minimal doses I'm gonna provide then so be it. But if a patient has a complaint or underlying condition that is associated with pain typically they deserve to be taken seriously and not dismissed because of how you perceive the patient to be.

If you have a patient who is all tatted up, wearing ragged clothes, lives in the projects, and is complaining of a 7/10 pain. Are you going to approach them differently than a non-tatted individual who is wearing nice clean clothes that you picked up in a middle-class neighborhood who is also complaining of a 7/10 pain? Which one is the drug seeker? If your Paramedic education or other clinical education allows you to make an accurate differentiation than that is awesome. But I highly doubt you can do that.

And for the record I am not advocating handing our pain meds like candy per every single request. I am saying it is irresponsible to withhold pain medications because of our own perception unless it is blatently obvious from past individual patient experience.
 
18G said:
If you have a patient who is all tatted up, wearing ragged clothes, lives in the projects, and is complaining of a 7/10 pain. Are you going to approach them differently than a non-tatted individual who is wearing nice clean clothes that you picked up in a middle-class neighborhood who is also complaining of a 7/10 pain? Which one is the drug seeker? If your Paramedic education or other clinical education allows you to make an accurate differentiation than that is awesome. But I highly doubt you can do that.
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Anecdotally, the nicer dressed middle class people are more often seekers than the tatted up guy with ratted clothing.
 
similarly for giving versed for someone faking seizures...i wouldnt do it. i dont believe it is punitive medicine either.
 
Angel said:
similarly for giving versed for someone faking seizures...i wouldnt do it. i dont believe it is punitive medicine either.
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There are some very convincing seizure patients.
 
DesertEMT66 said:
There are some very convincing seizure patients.
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True. I've given Ativan to a psuedo seizure patient that was well known to the other medics I worked with. I couldn't tell the difference. My opinion is that if you void on yourself during a fake seizure, you've put on a good show and earned a little candy.
 
TransportJockey said:
True. I've given Ativan to a psuedo seizure patient that was well known to the other medics I worked with. I couldn't tell the difference. My opinion is that if you void on yourself during a fake seizure, you've put on a good show and earned a little candy.
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I have the same view.
 
Amen. Best fake sz patient I'd ever had peed on himself AND bit his tongue enough to make it bleed. The doc said, "Congrats. You've been had." I said to the doc, "after that much effort, a little versed was the least I could do."

Oh well. It looked real to me.
 
I had one who was not only a perfect actor but someone also managed to be tachycardic as well. He was unknown to me and I brought him in Code 3. I was quite concerned about him because I thought he was in status. He had multiple "seizures" in the back of my ambulance. When I arrived at the ER, the doc made a face and said, "Oh yeah, that guy again, huh." He told me that the guy was a well-known drug seeker who had been in the ER the day before. The doc couldn't explain the tachycardia either. My best guess is that he was using meth.
 
We had a presentation once from a neurologist who showed us videos of patients having a variety of epileptic and non-epileptic events while undergoing continuous EEG. We failed badly at differentiating the pseudoseizures (or PNES, if you will) from the true epileptic events.

I've also transported patients who have had both PNES and epileptic events. Ultimately, you withhold benzodiazepines, and arrive at the ER, and any physician, no matter how wrong, decides this is an epileptic event, and now you're the paramedic who withheld benzo's from status epilepticus. Alternatively, you give the benzo's, the ER tells you this is a known PNES patient, whom they seem frequently, and you're the guy who got tricked. Some situations aren't winnable, but I know which way I want to lose, and I know which way I want my patients to lose.

One of the problems in EMS, is you rarely have access to objective details of their medical history. I think very few of us are able to tie into central databases on a call. So the ER may be able to pull up all the details of their prior ER and specialist visits, and what follow-up they've had, but we're usually guessing on someone we haven't encountered before.
 
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