But, but, people get
high on ketamine...
I agree, and wish we had ketamine at both analgesic and induction doses. However some of our ED docs seem uncomfortable with using it in the ED, much less on the trucks, citing concerns over emergence, misuse, security, diversion ect. I think alot of the push back is due to the area (we are rural Bible belt) and worries over the public finding out we gave little Johnny and acid trip after he suffered 3rd degree burns (although who
wouldn't want an acid trip after that?).RSI is an incredibly invasive answer to the problem. Give it a little time, maybe when ketamine is more safely established in the US (I know they've been using it for years overseas) and maybe we'll see it.
First and foremost, good to see you back. Happy Holiday.
But I wouldn't expect too much in the way of "advancement" in pain management, especially with ketamine in the US for the adult populations. (it is used mostly in peds)
The first problem is a new physician is likely to use what the old physician taught her. Which largely excludes ketamine.
Another major problem is some states, like my home, are trying to find a way to hold doctors responsible for patients who get addicted to prescription drugs. So pain management outside of the specialty isn't likely to be taking great leaps forward.
Finally, bible belt or not, US medicine can only be described as "adverse" to treating pain. There are still senior surgeons who like the idea of leaving a patient in pain to see if abd pain worsens instead of a serial ultrasound or CT scan. There are still other providers on a grand scale who think controlling pain will somehow mask something life threatening. Let's not forget the punitive medicine crowd who decides patients don't deserve or shouldn't be in that much pain.
Top it all off with an unhealthy dose of unfounded fear among a majority of providers who feel that proper pain management will result in death and all other kinds of worse than death scenarios.
Example, EMS with 2mg per dose max 10mg of morphine.
Indicated dose for analgesia, 0.15 mg/kg
a 70kg pt should recieve an initial dose of 10.5mg I think we both know that will never happen.
Even with newer things like fent, which has less "side effects" the doses are often limited to 50-100ug.
How about benzo/opioid synergy, 2-4mg morphine and 2-4mg versed, to treat nociceptive and psychological pain and in as little as 4-8mg total, you can all but absolve pain in most adults. Best of all the versed has very potentent amnestic effects, which really helps with kids, even in doses much smaller than conscious sedation.
But you won't even see EDs in the US using or even considering it. Even in patient populationss who have more psych aspect to their pain than nociceptive.
RSI for pain control? For irretractable pain in the most extreme of circumstances perhaps. But I can't really see it as an alternative just because the fent didn't work.
