Moving a Trauma Patient in severe pain without medications

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RuralEMS

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Patient today was in a Vehicle rollover that ended in the bottom of a very rural canyon. 1 patient was deceased on scene, 1 patient was critical but seemingly stable. Curled around a rock in a spot for terrible patient access. He could talk, Had deformity to his left
shoulder/Clavicle but not else obvious, he was in severe pain and said everything hurt. Even slight movements like attempting to to put on a BP cuff cause him to scream and wither in pain. Carry out was going to be super rough and was about .10 of a mile of side slope and slick River Rock. Lifeflight was only 20mins out, our only ALS, no other way to administer pain meds. Would you have tried to move this patient and carry him out without pain medication and ALS on scene? He's stable and not in any danger and being treated for shock as best as a EMT can do.


I only ask because during the call I had to defend my decision multiple times about not attempting to move/Backboard him immediately when I knew pain meds were 20mins out. I can't think of anyway severe pain can kill you, but it would have been brutal on this patient, Even after lifefight got on scene and gave him 2 doses of fentanyl, and 2 doses of ketamine this poor guy was still screaming in pain with every little unavoidable jostle. I can't even imagine what that would have been like without pain meds. Obviously it physically can be done, but I think In this scenario it was the best decision to wait an additional 20mins to have the drugs on Board before attempting to move/ backboard.
 
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You said critical but stable. Define critical. Critical how?
 
I mean he's been In a rollover into a Deep canyon that has resulted in the fatality of the other passenger. His vital signs didn't trend anything shocky and his ABC's were sufficient, A&Ox2. I'm just calling him critical based on MOI/Location. He's non-ambulatory and Slightly confused, but technically Stable based on vital signs/AVPU
 
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RuralEMS said:
I mean he's been In a rollover into a Deep canyon that has resulted in a fatality. His vital signs didn't trend anything shocky and his ABC's were sufficient, A&Ox3. I'm just calling him critical based on MOI/Location and Stable based on vital signs/AVPU
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I might just have trouble relaying it in writting,
He was hemodynamically stable, Nothing appeared appeared immediately life threating, I was just thinking in the back of my mind a high possibility of him becoming unstable, based on the Severe MOI and the fact that this patient was going to be on scene for a prolonged period of time.
 
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It seems like you're playing Monday morning EMT. Not necessarily a bad thing. Think about it this way. If you were to pull him out without medications and got him into the rig, would you have saved time meeting the heli? Was there a place for the, to land safely if you loaded and left? Would the patient have reached the point of passing out from the pain? The thing about most medications we give in situations like this is that 95% of the time the patient isn't going to remember what happened or that pain they experienced anyway.. or remember you for that matter. If it could have saved time, and you were worried about the patient deteriorating, sure getting him out without pain medications would have been okay. Doing what you did was okay. The point is in this situation you used your judgement and it sounds like he got there stably in the heli? The only reason this would be a bad thing is if he was not alert/ critical and you waited for ALS cause he was in pain. It sounds like you didn't do that so I wouldn't freak out. People are going to give you multiple opinions on this.
 
Thanks for the reply.

Is it common for patients to still be in severe pain even with 4+ doses of pain medications?

Plus waiting the additional 20mins allowed more time for non-medical folks to prep our walkout route, and For the sun to come up
 
You said that he was only A/Ox2, so an altered trauma patient. My thought on multi-system trauma, especially head trauma, is get them to a trauma hospital as soon as possible because that's the only place that can fully treat these patients.

Also keep in mind, say we do wait on scene and he starts to deteriorate, are we going to be able to effectively treat him while carrying him to the LZ?

So my take on this call would be to package him as quickly and painlessly as possible, and get him to the bird.
 
It did say alert and oriented x2. So you will have to clarify that. But yeah some people have different pain tolerance levels. Some people just don't have the therapetic response at lower doses. Some people are in so much pain and for good reason because they have a broken hip or an open femur fracture. It just depends.
 
This is the one situation I have to hand it to methoxyflurane, it's much more portable than an entonox cylinder.

Pain relief is often difficult and there is very good evidence it's best done by more than one method; both medicines and other things such as distraction. This is why having multiple tools is best; intravenous analgesia is good but works much better in combination with an inhaled agent. In some circumstances there is also the use of nerve blocks; particularly using USS.

The answer however, is pretty simple, if you can't move the patient cos they're in pain; well, give them pain relief. It also takes time. I have spent up to an hour on scene while we sorted out somebodies pain to the point they could be extricated.
 
Pain is weakness leaving the body lol....or "pain is a non fatal problem".

Sure, I'd like to effectively medicate it, but if I can't, we can go without. I'd rather a patient pass out from pain while packaged and being safely moved to an LZ than pass out wrapped around a weird rock. This guy sounds badly injured, to the point where I would consider him to be emergent, and 20+ minutes to ALS contact is a long time to wait.
 
RocketMedic said:
"pain is a non fatal problem".
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pain sucks, but few people die from pain. If you can give pain meds, by all means do so. But if they are unavailable (at the current time, due to a 20 minute ETA), you want to wait?

This guy sounds messed up, the crash killed another person in the car, and he sounds like he has a head injury at least. He needs a trauma surgeon to make sure he doesn't die.

Tell him it's going to suck, make it hims comfortable as you can, and do your best to extricate him and get him to the LZ.

Wait.... are you having the helicoper land in the bottom of the canyon? or will you still need to move him from the car to the helicopter?

Keeping the golden hour in mind (despite evidence that an hour doesn't mean much anymore), you still want to get the patient to trauma center as soon as possible. you have a 20 minute delay (for the helicopter), plus another 20 minutes from the time the crash occurred until the time you showed up at the car, and now you want to delay further until the medical crew lands grabs all their gear, and starts making their way to the crash site, through ".10 of a mile of side slope and slick River Rock"? And as you found out, it's going to suck regardless, even after the pain meds.
 
Once again, Thanks for the replys.

Honestly IRL the wait time between us being prepared to move without pain meds and than deciding we were going to wait for lifeflight was about 5mins. They were able to land on the road in the canyon bottom and be on with us and the patient in less than 10mins. They auto launched on this call, but I'm trying to be hypothetical about the typical 20min response time.

We definitely wanted to get him moving, he'd been down there atleast an hour before we were on scene, but just as we got to the point of arranging the backboard, We heard the helicopter. Honestly I also think we wouldn't have really gained any time since people were still scouting and creating a walking route out of the canyon.
 
Every flight service is different and I am assuming since this may be a somewhat common type of call in your area that they may be trained and comfortable with it however most Flight Crews are not going down that canyon to the patient, you are bringing to patient to them. Although many would be willing to do so they are limited by their company's policy.

Pain management is great but low on the hierarchy of needs.
 
RuralEMS said:
I mean he's been In a rollover into a Deep canyon that has resulted in the fatality of the other passenger. His vital signs didn't trend anything shocky and his ABC's were sufficient,
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The only thing that would matter to me is the death of the occupant. See below

A&Ox2
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This is clinically relevant

I'm just calling him critical based on MOI/Location.
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MOI is a poor to ineffective predictor of the patients condition and outcome. I have almost eliminated the concept of MOI from my mind and only take it it as clues to direct my assessment. There is a reason why MOI is a 3rd line trauma inclusion criteria. This patient probably had a GCS below 14 if he was x2, which would be a 1st line inclusion. This patient is getting rapidly packaged and carried out. Sucks for him but my HEMS isnt coming down to us so i have to bring the patient to them. Its the time to do a good physical assessment, roll onto the board and into the stokes. Packaging shouldnt take more than 5 minutes if your using webbing lashing
 
Im gonna go a different route then the people above me. If he is hemodynamically stable (Shock index, BP, MAP, cap refill) then you need to treat pain prior to movement. It shouldnt take long to deliver pain medication (IV, IM, IN) along with proper splinting of affected areas to reduce pain. treating someones pain is one of the greatest skills we have as clinicians and should not take it lightly. These types of patients can often times get PTSD not just from the event but the pain associated with it. There are studies stemming from the war that talks about ketamine/ lidocaine administration and the prevention of 'the pain wind up' and how it decreases opiod use during rehab, the thing is the closer to time of injury the greater the benefit.

I once listened to a lecture of a guy who was hit head on by a drunk driver and he talked about how the PTSD from it destroyed his life, he could no longer drive due to the fear he had. He said he could never forget the pain of being pulled out of his car and that he could feel that same pain sometimes at night.

So saying nobody dies from pain is a true statement, but its one without the patients best interest in mind. We now have so many ways to treat pain (tordal, tylenol, ketamine, fent, air splints, KED instead of backboard) to totally disregard them is not appropriate in my opinion. All of this is patient and situation permitting, i understand this was a difficult call, but i still believe it can be addressed at least to some degree.
 
Hi Rural EMS. A question first. Does your service not kit you out with analgesia? Our non-intensive care level of paramedics have analgesia that can be delivered by just about every route save PR. IN, IM, inhaled and IV meds. Like your own, our time critical guidelines would categorize this patient as time critical based on mechanism. What can be achieved in this case with forced rapid extrication by stressed EMT's given you are going to wait for the helo paramedics anyway? And what will happen to his cardiovascular obs when you pull him out with no meds/no IV/fluids given his level of pain and unknown concealed injuries? Sit on your hands and take a breath. Do what you can do, look for options on how you get your obs because you need info as a baseline despite the pain. Leg BP?, using your pulse ox for the HR etc. And above all, embrace the concept of futility without guilt - you can only do what you can do.
 
I personally don't think waiting 20 minutes for a flight crew/ALS was a good idea. First, since you aren't that crew, how would you know they would even give it? What if you waited 20 minutes and they didn't give it (eg maybe it's contraindicated in their standing orders)? Then, like in your example, how do you know that it would even help? It sounds like in this case, the patient was still in agonizing pain even when being moved after pain medications. To me, it sounds like you took a chance. I think it would've been better for you to move the patient than to delay transport. There was one study I believe from Pennsylvania where major trauma patients (gun shot wounds?) had better outcomes going by law enforcement than by ambulance. It's just a study, but one of the thoughts was that it could be delayed transport (backboarding, starting an IV, vital signs, maybe pain management) or harmful medical care (eg giving a hemorrhaging patient too much fluids). After reading a couple of studies and thoughts related to trauma care, I feel like it is better to focus on getting the patient to a trauma team/surgeon than it is to worry about "now". I think one of the members here wrote a really good thing about "death by checklist" where we have the tendency to try to finish all of our treatment before the patient gets to the hospital, and sometimes we just need to say that it is not good for the patient or it is not good to delay transport in these cases. I just typed in the title in Google and found it. http://emsbasics.com/2014/07/19/murder-by-checklist/
 
RuralEMS said:
Is it common for patients to still be in severe pain even with 4+ doses of pain medications?
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‘It’s the dose that makes the drug’.

TXmed said:
So saying nobody dies from pain is a true statement, but its one without the patients best interest in mind.
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I feel like this is ‘patient advocacy’ 101.


Question to the group:

How do we feel about analgesia in the setting of head trauma?
 
CWATT said:
How do we feel about analgesia in the setting of head trauma?
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As in the TBI patient?

Provided that they’re hemodynamically stable, and other causes have been ruled out, I fail to see much difference in providing proper pain management via analgesics with, or without sedatives behind them...similar to what’s seen in ICU-level critical care patients whose CPP’s are being maintained at a mandatory minimum parameter.

We really don’t know what we don’t know, and I cannot stress that ENLS course enough. Even basic maneuvers such as keeping the patients head elevated and/ or neutrally in-line (blasted snug c-collars!) in order to promote cerebral perfusion.

Rant aside, it’s not uncommon for the borderline GCS patient who may not immediately require advanced airway management to receive proper analgosedation by us prior to, and/ or even in-flight; think DSI.

ETA~ the Monroe-Kellie Doctrine is not a fallacy.
 
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