Morphine Administration

[medicRob]

I just have to vent..

The other night, I did a floating shift in the ER of a busy trauma I center. Long story short, I had a patient who came in complaining of severe pain in his tooth, and when I had him open up to examine, sure enough his back molar was covered in blood with a huge hole in it.. I asked him how long he had let that go on.. He replied, "This started over 3 weeks ago, and I have no insurance.. ", to which I said, "well, why didn't you come here earlier? We can't deny you treatment on the basis of no insurance."

The patient replied with something that got me so pissed with our system today. He said with the look of desperation in his eyes, as he held his jaw, "I was afraid they would label me as a drug seeker"..

We have to quit this s### about withholding pain meds cause we have an inclination that the patient may be faking the pain. Last time I checked, my nursing textbooks told me that the patient has the right to not be in pain and that we, as providers cannot definitively say "Yes, this person is in pain" or "No, this person is not". Patients come to us in times of desperation for help and put their confidence in our abilities to do so. If my patient tells me they are in pain, and I believe that pain is to a level that would require pain medicine, I will go through the appropriate steps to administer it, whether it be something that requires me to contact medical control to ask for permission or if it is standing order. This patient went for 3 weeks with a tooth that was abcessed so horribly that the entire right side of his face was swollen, all because he was afraid someone would label him a "Drug Seeker". Thank God he came to us when he did so the doc could first and foremost give him antibiotics, the number of a dentist that helped people without insurance, an application for Tenncare, and a prescription for a few hydrocodone.

I am getting irked just typing this, it pisses me off so much.

 

[WTEngel]

I agree. Part of being a patient advocate is giving our patients the benefit of the doubt. If they say they are in pain, we should believe them and try to treat it.

Frankly someone being a drug seeker isn't of too much concern to me. I don't want to contribute to anyone's drug addiction, but I certainly don't want to withhold pain medication from a patient in pain...which I risk if I decide to withhold meds.

 

[medicRob]

I agree. Part of being a patient advocate is giving our patients the benefit of the doubt. If they say they are in pain, we should believe them and try to treat it.

Frankly someone being a drug seeker isn't of too much concern to me. I don't want to contribute to anyone's drug addiction, but I certainly don't want to withhold pain medication from a patient in pain...which I risk if I decide to withhold meds.

The consequences of giving a junky another fix is far less than the consequences of withholding pain management from a patient who actually needs it. Therefore, as long as I can administer pain meds and the patient is physiologically sound enough to maintain such medications, I will give them with respect to the severity and duration of the pain in question.

 

[rhan101277]

I had a medic once tell me that their pain isn't going to kill them. Maybe so, I think many who withhold pain medicine are just lazy and do not want to fill out the paperwork.

 

[rhan101277]

"Would you like something for the pain?"


If yes, give it. If slapped on the hand for it not being a 5, then everyone in pain becomes a 5.

Yes I remember reading this somewhere. I will start trying it. If they say "yes" then they get at least a six out of 10.

 

[johnrsemt]

I used to work with alot of medics who stated that they did not want to cause their patients to 'become addicted' to pain meds.

there is a major Level I Trauma Center in the Midwest that has been doing an ongoing study for over 7 years about that: they have had 3 patients out of over 100,000 that have been given pre hospital pain meds that have come out of the hospital addicted: all 3 were in the ICU for over 2 weeks and 2 were addicts before hand.

I treat my patients to the best of my ability and alot of times that is treat pain. So I do

 

[Dave 52-4]

I tend to look at my assessment objectively rather then taking a singular subjective complaint at face value.

DOI, MOI, objective findings in my secondary assessment.

1) Pain never caused anyone to expire.
2) Masking what should be obvious symptoms to the receiving physician I think a mistake.

With that said I find myself using MS04 in cardiac settings a great deal more then general medical issues. Trauma being the exception and even then I find good splinting and positioning the key to a good trip.

At the end of the day I follow my my standing orders realizing they are a simple guide, not the law. One size does not fit all.

I do not with hold it, but, it ain't candy on the shelf at Walmart either. BTW we carry Fent, MS, and Demerol.

Just my thoughts.

 

[usalsfyre]

I tend to look at my assessment objectively rather then taking a singular subjective complaint at face value.

DOI, MOI, objective findings in my secondary assessment.

Curious as to how you objectively evaluate a purely subjective complaint.

1) Pain never caused anyone to expire.
2) Masking what should be obvious symptoms to the receiving physician I think a mistake.

1.Prove it. You can't anymore than I can prove it did
2.Properly administered pain control AIDS in diagnostic efforts. Studies back this up.

With that said I find myself using MS04 in cardiac settings a great deal more then general medical issues.

So an MI is more worthy of appropriate treatment than say cholecystitis or renal colic?

Trauma being the exception and even then I find good splinting and positioning the key to a good trip.

You find it is or do your patients?

At the end of the day I follow my my standing orders realizing they are a simple guide, not the law. One size does not fit all.

Agreed, but what you described is text book crappy EMS pain management. Let the patient suffer, because we're scared of narcs.

I do not with hold it, but, it ain't candy on the shelf at Walmart either. BTW we carry Fent, MS, and Demerol.

Just my thoughts.

That's a contradictory statement if I ever heard one, not to mention you admitted to withholding meds from medical patients earlier. What harm is the small amount of narcotics you administer (assuming you do it appropriately) going to cause? When you can articulate that, come back to me.

 

[Jay]

Anyhow our protocols say that pain management is indicated on any isolated extremity injury with pain scale greater than 5 out of 10.

That's Poppycock! How about they become proponents of treating the patient and not their numbers. Every service, hospital is different, for example VA Hospitals use 7 or above for their number, others 6, etc. But you can usually tell if someone is in severe pain and based off of how they present, an educated (pronounced "fair") responder will treat pain based off of that. The other problem is that a "broken finger" for one may not be as bad as a kidney stone or as bad as back pain with someone with severe stenosis. Since 85% (or around that number) of pain is idiopathic anyways, the treatment needs to be based off of several factors that would ultimately be beneficial to the welfare of the patient.

Also, many of times I discovered that copious O2 will drastically reduce the pain reported after 5 minutes, this goes for MI or trauma. Each patient is different though.

 

[Dave 52-4]

Curious as to how you objectively evaluate a purely subjective complaint. It is rather easy, it is called a secondary assessment, ergo, what I typed above, DOI, MOI add to that a pertinent history and whala you are actually doing your job



1.Prove it. You can't anymore than I can prove it did Misnomer here, I will disregard
2.Properly administered pain control AIDS in diagnostic efforts. Studies back this up. Name your studies ad-hoc or not, would love to see them..Maybe I would learn something, that is why we are all here at the end of the day


So an MI is more worthy of appropriate treatment than say cholecystitis or renal colic? Yep, that's right an MI will kill you en route renal colic is a taxi cab issue, even in Dialysis patients

You find it is or do your patients? I have had a rather large success with positioning and splinting, but, that takes time and energy, more so the sticking an 18 short and breaking a plastic lock



Agreed, but what you described is text book crappy EMS pain management. Let the patient suffer, because we're scared of narcs. that is not what I said, re-read my post.



That's a contradictory statement if I ever heard one, not to mention you admitted to withholding meds from medical patients earlier. What harm is the small amount of narcotics you administer (assuming you do it appropriately) going to cause? When you can articulate that, come back to me.

I have little time for cookie cutter medics that do not have the knowledge, skill or were with all to access a patient, when you get to that level, look me up. But be it known, I am always willing to teach, ALWAYS....

Be well.

 

[Smash]

I tend to look at my assessment objectively rather then taking a singular subjective complaint at face value.

DOI, MOI, objective findings in my secondary assessment.

1) Pain never caused anyone to expire.

Perhaps not, but it causes increased length of stay in hospital, poorer prognosis from multiple disease process, modifies inflammatory and coagulatory processes, increases the rates of re-presentation and readmittance, causes loss of function, depression, anxiety, insomnia.... the list goes on.

2) Masking what should be obvious symptoms to the receiving physician I think a mistake.

Good God, Zachary Cope is dead, can't we put his ghost to rest as well? As usalsfyre has pointed out, analgesia is useful in aiding diagnosis, not masking it. It allows the the blunting of the distress that comes with pain (the affective part of pain) so that the patient can more accurately describe the pain and other symptoms without being distressed and distracted:

Dahl JL, Berry P, Stevenson KM, Gordon DB, Ward S. Institutionalizing pain management: Making pain assessment and treatment an integral part of the nation's healthcare system. APS Bulletin 1998; 8(4): 6. (s)

Wolfe JM, Lein DY, Lenkoski K, Smithline HA. Analgesic administration to patients with an acute abdomen: a survey of emergency medicine physicians. AmJ Emerg Med 2000; 18:250-253. (s)

Pace S, Burke TF. Intravenous morphine for early pain relief in patients with acute abdominal pain. Acad Emerg Med 1996; 3:1086-1092. (s)

Attard AR; Corlett MJ; Kidner NJ; Leslie AP; Fraser IA. Safety of early pain relief for acute abdominal pain. Br Med J 1992; 305: 554-556. (s)

Thomas SH, Silen W, Cheema F, Reisner A, Aman S, Goldstein JN et al. Effects of morphine analgesia on diagnostic accuracy in emergency department patients with abdominal pain: a prospective, randomized trial. J Am Coll Surg 2003; 196(1): 18-31. (s)

Wolfe JM, Smithline HA, Phipen S, Montano G, Garb JL, Fiallo V. Does morphine change the physical examination in patients with acute appendicitis? Am J Emerg Med 2004; 22(4): 280-285. (s)

Kim MK, Strait RT, Sato TT, Hennes HM. A randomized clinical trial of analgesia in children with acute abdominal pain. Acad Emerg Med 2002; 9: 281-287. (s)

Thomas SH, Silen W. Effect on diagnostic efficiency of analgesia for undifferentiated abdominal pain. Br J Surg 2003; 90: 5-9. (s)

Mahadevan M, Graff L. Prospective randomized study of analgesic use for ED patients with right lower quadrant abdominal pain. Am J Emerg Med 2000; 18: 753-756. (s)

LoVecchio F; Oster N; Sturmann K; Nelson LS; Flashner S; Finger R. The use of analgesics in patients with acute abdominal pain. J Emerg Med 1997; 15: 775-779. (s)

Vermeulen B, Morabia A, Unger PF, Goehring C, Grangier C, Skljarov I, Terrier F. Acute appendicitis: influence of early pain relief on the accuracy of clinical and US findings in the decision to operate--a randomized trial. Radiology 1999; 210: 639-643. (s)

Nissman SA; Kaplan LJ; Mann BD. Critically reappraising the literature-driven practice of analgesia administration for acute abdominal pain in the emergency room prior to surgical evaluation. Am J Surg 2003; 185(4): 291-296. (s)

Manterola C, Vial M,Moraga J, Astudillo P. Analgesia in patients with acute abdominal pain. Cochrane Database of Systematic Reviews 2007, Issue 3.

So an MI is more worthy of appropriate treatment than say cholecystitis or renal colic? Yep, that's right an MI will kill you en route renal colic is a taxi cab issue, even in Dialysis patients

I'm blown away by that comment. My only hope is that I never suffer from such an illness in your patch of the woods, or maybe that you do in someone else's who has the same attitude.

I'm pleased you are always willing to teach; I'm just not sure that I would like people learning this approach to patient care.

 

[alphatrauma]

I don't withhold pain meds. If I believe my patient is in pain or my patient tells me they are in pain, I will administer them. I will leave it to the ER docs to play the little, "Who's a drug seeker game" .. I personally try not to pass such judgements.

^ This!

 

[Dave 52-4]

I'm pleased you are always willing to teach; I'm just not sure that I would like people learning this approach to patient care.

To each their own, I believe that there are many roads that lead to the same fruition in any given scenario. With good medical direction, a quality QA/QCI program that includes agressive training I believe these issues would be nill at best.

I, again, never stated pain control should not be used, my point is that it should be based upon sound assessment and good judgement, not dispensed in a cookie cutter fashion - IE anyone everywhere.

Good points made here however, yours included.

 

[usalsfyre]

It is rather easy, it is called a secondary assessment, ergo, what I typed above, DOI, MOI add to that a pertinent history and whala you are actually doing your job

Again, please explain to me how you asses this? Pain is by all measures a SUBJECTIVE complaint. I know of no one who has figure out how to truly objectively asses pain (but I have met lots of people who think they can).

Name your studies ad-hoc or not, would love to see them..Maybe I would learn something, that is why we are all here at the end of the day

See Smash's post

Yep, that's right an MI will kill you en route renal colic is a taxi cab issue, even in Dialysis patients

Considering dialysis patients aren't using their kidneys for elimination I would hope not. However, remind me to never have an extremely painful, yet non-life threatening in the view of EMS, condition in your town. Because the care I would get would be substandard.

I have had a rather large success with positioning and splinting, but, that takes time and energy, more so the sticking an 18 short and breaking a plastic lock

So I'm not sure exactly what your trying to say here (local terminology?) but I find positioning and splinting to be very helpful as well. I also find a good dose of fentanyl IN or IV BEFORE I start performing a potentially painful procedure (splinting) makes my patients much happier and easiser to deal with. If I could, I'd slip them some midaz as well to make the experince much more pleasant/foregetable.

that is not what I said, re-read my post.

Then explain how it means something different.

I have little time for cookie cutter medics that do not have the knowledge, skill or were with all to access a patient, when you get to that level, look me up. But be it known, I am always willing to teach, ALWAYS....

Very, very far from a cookie cutter medic here. I'm always willing to learn, but I have a feeling you have very little to teach on this subject. You describe the typical paramedic approach to pain, "it's not important enough for me to deal with".

If you are so willing to teach, please explain to me why pain management is bad, why letting patients suffer is good, and how one or two doses of narcotics, administered correctly, for painful but "non-emergency" conditions is detrimetal to patient care?

 

[mc400]

I withhold pain meds very rarely. If you tell me you are in pain and it is within my protocol to help ease that pain I will do so. Many of my transport times are 20-40 minutes so some zofran usually comes with it too. We only carry MS but hopefully soon fentanyl will be available.

Not treting pain is a thing of the past. Also I agree with usal splinting and positioning is much easier and less painful fr the pt if there is some drugs on board, we always try to give MS and depending on the patient a benzo when positioning and splinting a fracture or moving a fractured hip/femoral head patient. It makes no sense not too.

 

[jjesusfreak01]

Have to agree here. There is no reason in EMS to withhold pain medications. They have short half-lives, so honestly if you want a high, EMS isn't the best way to do it. Now, drug seekers at the hospital are another problem entirely...

 

[Veneficus]

As for objectifying pain, I tend to use the FLACC scale. It helps not only with children or the cognitively impaired but also with those who cannnot be effectively communicated with like languages I don't speak.

Personally I always err on the side of the patient. Nobody will ever rightfully accuse me of not liberally treating pain.

Even if you have to call med control sometimes a benzo and opioid mix will go father than simple high dose opioids.

Medicine cannot cure all ills, but since the very foundation it has had the ability to reduce pain.

There are actually conditions where the pain is diagnostic, but I advocate finding another way. Since we have the means in 2010, leaving a patient in pain is just outright mean.

 

[Shishkabob]

Someone at my agency screwed the pooch with our pain control. Up until last week, we had 1-2mcg/kg Fentanyl for anyone in pain, can be repeated without consult, and if pain still wasn't controlled we could consult with MC about RSIing.

Well, got a memo last week... now it's just 1mcg/kg for people above 10years and below 70years. (Though we can still do 3mcg/kg as pre-medication for RSI)

 

[Smash]

Someone at my agency screwed the pooch with our pain control. Up until last week, we had 1-2mcg/kg Fentanyl for anyone in pain, can be repeated without consult, and if pain still wasn't controlled we could consult with MC about RSIing.

Well, got a memo last week... now it's just 1mcg/kg for people above 10years and below 70years. (Though we can still do 3mcg/kg as pre-medication for RSI)

How does med control feel about RSI for pain relief only? Does it happen often, and in what sort of settings? I presume the rationale is to allow heroic doses of sedation and analgesia to manage pain without fear of respiratory/airway compromise.

 

[Shishkabob]

To be honest, I'm too new here to know how often it's used, usalfyre will be of better assistance there, but yes I would presume it would be in an attempt to give ungodly amounts of narcotics as, atleast in my county, we're 45min-1hr+ away from anything that resembles a hospital.