Pain Control

[Shishkabob]

Guess what? If you don't care about even attempting to help most of your patients pain, you are not a good provider, you never will be, and anyone who says you are is sadly mistaken.



The Paramedic who relieves me constantly calls me out for my aggressiveness of pain control (ex- 250mcg Fent and some Ativan for a tib/fib last week) and boasts that she has given pain control MAYBE 3 times in the past year, and that I have the "New medic med push syndrome" where I just want to push a med (though she's never been on a call with me). Maybe she's just angry that she has to go to the pharmacy to refill the narcs...



Just can't get through to some people. We have aggressive pain control guidelines for a reason...

 

[Epi-do]

Eh....she'll get over it.

I tend to get razzed from time to time about letting the fentanyl flow more freely than a lot of the other medics I work with as well.

 

[LucidResq]

Kinda baffles me... I mean, after getting people to a doctor, I would hope making them feel better would be goal #2.

For some reason it reminds me of how I've had certain dentists hesitate to give me nitrous. The stuff will wear off before I get out of your chair, it reduces anxiety and pain for me, and I'm paying for it. But Mr. Dentist (or ER doc in the EMS equivalent) will happily leave me a script for Vicodin with my discharge paperwork that I could theoretically go home and take 20 of and sell the rest? That's what I don't understand. Granted, it's not the medic writing the script, and I've heard of dentists/doctors that are less friendly with the carry-out opiods, but honestly, I've yet to meet one.

Am I the only one that's noticed this phenomenon? I'll tell you when I ended up in the ED a few months ago for severe abd pain, I only got IV Zofran and fluids while curled up on the bed wincing in pain, but left with an RX for Vicodin to fill at Walgreen's.

 

[Shishkabob]

I make it a habit to give my final bit of Fent (50mcg or so) just as we pull in to the ER bay so they have SOMETHING while waiting.

 

[rhan101277]

Initially after my first administration of morphine, I will ask the patient if they would like more pain medicine. I will usually give 2-4mg of morphine and then see how it goes, if they are sedated, zonked out or what not then I don't give anymore or even ask. If they are still AAOx3 and they are still hurting but not to the point where I can tell, I will ask would you like more pain medication. Most people say no thanks, that helped alot. I have only given morphine three times since I have been cleared paramedic, which was since January.

I to believe in pain management, after all they are paying for an ambulance ride. Why not give them the care that you can?

 

[Veneficus]

I think Linuss is exactly right on this one.

I have noticed in my travels that managing pain seems to be a problem in the US.

For some reason, despite the managment of pain being one of the oldest functions of medicine, US providers seem to be taught to fear the use of analgesia and there is a cultural bias against those who would make use of it.

Narcs and benzos together, there is hope for at least one excellent provider. Now if only the rest of the country would catch on.

 

[Bieber]

I'm always baffled at how many of my colleagues seem to emphasize (proudly) how they're not "candy stores" and that "you have to be in a lot of pain for me to give you anything". There's not a lot of evidence suggesting what we do is all that valuable, but pain control is certainly one of those areas where we in EMS CAN and DO make a valuable difference.

Unfortunately, I'm sad to say that my protocols are rather limiting when it comes to pain control. Chest pain, abdominal pain, and isolated injuries. Absolutely no pain control for polytrauma, and benzos are for seizures and sedation for cardioversion (which, unless it's V-tach, we need to get an order for). Hopefully things will change soon, but it's a rather conservative medical community around here (which I find somewhat ironic considering here in Kansas we're one of the few states that requires a degree to become a paramedic).

Kinda baffles me... I mean, after getting people to a doctor, I would hope making them feel better would be goal #2.

Not to get off topic, but this comment stuck out to me and I'd like to ask you: is the goal really to get patients to a doctor (period), or to provide patients with the most appropriate medical care (whatever form it may take)?

 

[cruiseforever]

Had a co-worker that thought pt's having pain from kidney stones were just a bunch of cry babies. He ended up getting them twice. Since that time he has changed his tune and now treats pain with a vegence. There has to be a God.

 

[Aidey]

I think Linuss is exactly right on this one.

I have noticed in my travels that managing pain seems to be a problem in the US.

For some reason, despite the management of pain being one of the oldest functions of medicine, US providers seem to be taught to fear the use of analgesia and there is a cultural bias against those who would make use of it.

Narcs and benzos together, there is hope for at least one excellent provider. Now if only the rest of the country would catch on.

Narcs and benzos together?!?! THAT IS CONSCIOUS SEDATION!!!!! YOU CAN'T DO THAT !!!11!

At least that is the attitude around these parts with my fellow paramedics. Thank goodness the ER MDs don't seem to agree. I called for orders one time for a teen with a shattered femur so I could get versed to add to the fent I had already given her. The MD told me to have at it, keep an eye on her breathing and not to exceed 10mg.

I've tried explaining the difference between a conscious sedation dose and an anti-anxiety/muscle relaxant dose, but I haven't gotten anywhere.

As I've mentioned before, my personal problem with pain control is lack of options. I've got fent and that its it.

 

[usalsfyre]

There's a massive cultural bias against pain management in EMS. Providers who appropriately manage pain are seen as "weak" and "gullible". Like Linuss says, there's some who see it as a badge of honor NOT to give out narcotics. You gave to "prove" your pain to these people. There also the folks that will say an ambulance "isn't a damn taxi". The only place I haven't consistently encountered a large percentage of these medics is in CCT.

I've been on the other end. I've experienced a painful injury, and received no pain management from EMS or the ED. This transpired after I was an EMS provider, and had seen the pain management light. It sucks and is providing $hity medical care. If your not managing your patients pain appropriately to the extent allowed under your protocols, guess what, YOU suck as a medic.

What pisses me off about medics in my own service who do this is I was one of the guys jumping up and down screaming in the clinical services office about the homeopathic doses of morphine we used to have written in our protocols. To me, consistent failure to manage pain should be treated the same as any other consistent clinical failure. Remediation, discipline and termination.

 

[usalsfyre]

Narcs and benzos together?!?! THAT IS CONSCIOUS SEDATION!!!!! YOU CAN'T DO THAT !!!11!

LOL, I actually told him the same thing (with the same sarcasm)about another issue off-line earlier today .

We can't technically do narcs and benzos together for straight pain control without an online order. Which can be a pain to get depending on the doc and dispatch. However, benzos are rather liberally dosed for agitation in our guidelines. To me, anyone who can't sit still, is screaming, ect due to pain is agitated. Walla, narcs and benzos together...

 

[Shishkabob]

Heh, like I told you before usal, I like doing the "Hey, they're screaming, they obviously aren't happy, therefore they're agitated!" route... but I still called in my Ativan on the tib/fib guy JUST to cover my bases, and the doc I spoke with (Dr Cameron... still have to meet the guy) said "Sounds reasonable to me, go ahead"

 

[Aidey]

....I was one of the guys jumping up and down screaming in the clinical services office about the homeopathic doses of morphine we used to have written in our protocols....

I am so stealing that.


We technically can't either, and depending on the case I justify it the same way you do. I am more apt to call for orders if it is a fringe case (like my teenager who was about 90lbs). If it was up to me we would have dosing protocols for benzos to use as a "muscle relaxant".



On a side note, there was a case recently where a 115lb female with 25% 2nd degree burns was given.....wait for it....wait for it.....65mcg of fentanyl during a ~20 minute transport.

 

[usalsfyre]

Heh, like I told you before usal, I like doing the "Hey, they're screaming, they obviously aren't happy, therefore they're agitated!" route... but I still called in my Ativan on the tib/fib guy JUST to cover my bases, and the doc I spoke with (Dr Cameron... still have to meet the guy) said "Sounds reasonable to me, go ahead"

I understand completely why you called. I probably should on some occasions too. I'm just too much of a h34r: medic sometimes. What's the fun in coming to work if you can't be subversive .

 

[Icenine]

Eh....she'll get over it.

I tend to get razzed from time to time about letting the fentanyl flow more freely than a lot of the other medics I work with as well.

Keeps it from sitting in the truck expiring...

 

[Veneficus]

Narcs and benzos together?!?! THAT IS CONSCIOUS SEDATION!!!!! YOU CAN'T DO THAT !!!11!

At least that is the attitude around these parts with my fellow paramedics. Thank goodness the ER MDs don't seem to agree. I called for orders one time for a teen with a shattered femur so I could get versed to add to the fent I had already given her. The MD told me to have at it, keep an eye on her breathing and not to exceed 10mg.

I've tried explaining the difference between a conscious sedation dose and an anti-anxiety/muscle relaxant dose, but I haven't gotten anywhere.

As I've mentioned before, my personal problem with pain control is lack of options. I've got fent and that its it.

When you use opioids and benzos together you use less overall than you would using just one.

People need anesthesia teaching pain control, they are the only ones who get it right.

 

[usalsfyre]

I am so stealing that.

To be fair, I stole it too (from either Rogue Medic or Kelly Grayson's blog).

On a side note, there was a case recently where a 115lb female with 25% 2nd degree burns was given.....wait for it....wait for it.....65mcg of fentanyl during a ~20 minute transport.

I don't know why this crap goes on. Let me burn THAT medic over 25% of his body and see how satisfied he is with 65mcgs of fentanyl...

 

[Aidey]

When you use opioids and benzos together you use less overall than you would using just one.

People need anesthesia teaching pain control, they are the only ones who get it right.

I know. I was just a little surprised that the MD authorized up to 10mg of Versed in a 90lb patient when he knew I was mixing it with fentanyl. I think I ended up using 1mg of versed and 150mcg of fent? It was a while ago, so I can't remember exactly. I do know that when I dropped her off I had managed to hit the sweet spot, where her pain was significantly reduced, and she wasn't overly sedated.

 

[usalsfyre]

People need anesthesia teaching pain control, they are the only ones who get it right.

AbsoFreakingLoutely!

But there's too many medics out there that think the only people who can teach EMS are medics, or maybe an EM physician (who preferably used to be a medic) because "we do it in the streets" .

 

[Shishkabob]

I know. I was just a little surprised that the MD authorized up to 10mg of Versed in a 90lb patient when he knew I was mixing it with fentanyl. I think I ended up using 1mg of versed and 150mcg of fent? It was a while ago, so I can't remember exactly. I do know that when I dropped her off I had managed to hit the sweet spot, where her pain was significantly reduced, and she wasn't overly sedated.

Oh yes, the sweet spot. I got my tib/fib guy to that zone to where it only caused pain/discomfort when we moved him. Just so happened that it took 250mcg/fent and 0.5mg Ativan. The receiving doc was shocked at the 250 at first, till I reminded him that it was nearly an hour transport.

I typically aim to cut the pain in half at least... 10 to a 5, etc etc.

I understand completely why you called. I probably should on some occasions too. I'm just too much of a h34r: medic sometimes. What's the fun in coming to work if you can't be subversive .

I told you earlier how I was h34r: like today... your evil habits are rubbing off on an impressionable newbie!