Pain Control

[medic417]

Can you show me any area which has more than 10mg of morphine or equivalent on standing order, or has standing order morphine+midazolam, or has ketamine or any sort of combination analgesia?

Brown has seen one area (Wake County) has entonox and it's a Paramedic (ALS) level skill for frig sake, back in 1975 our one week trained Elementary Ambulance Aid Officers could give entonox.

I can administer Morphine (carry 50mg minimum ), Fentanyl ( carry 500mcg minimum ) , Ketamine, Versed, Toradol, Nubain, and many more on standing orders to get patient relief, no maximimum. If they hurt we treat.

 

[reaper]

Hit them with a D cylinder. They won't hurt any more! Saves money!

 

[usafmedic45]

The service I was a supervisor with had nitrous as the BLS measure for pain control. The state wasn't happy about it, but to quote our medical director "You're not the one with a medical license so I think you can figure out what part of my anatomy to stimulate your gag reflex upon. Good day sir."

(...and you wonder where I get the attitude from?)

 

[Shishkabob]

Can you show me any area which has more than 10mg of morphine or equivalent on standing order, or has standing order morphine+midazolam, or has ketamine or any sort of combination analgesia?

Errr.. mine and usalfyres agency.


We have 1250mcg of Fent on our truck, and no true maximum, just a "consider calling for consultation for something more effective"


Also have Ativan and Versed for "agitation" (our call who's agitated)

 

[usafmedic45]

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

...or some oncologists. One of the best pain control folks I've ever met was an oncologist I worked with in the Air Force. She's the one who taught me not to be afraid of narcotics and introduced me to the marvels of ketamine for otherwise intractable pain.

 

[Shishkabob]

Or a burn ward doctor...




Narcs don't scare me, we have Narcan. Amiodarone and Lidocaine in a conscious patient? Yeah, that scares me.

 

[usafmedic45]

To quote a slide from the presentation I do on palliative care: "You can save someone's life but leave them in pain and they will curse your name for the rest of their days. You can be powerless to save someone but ease their pain and they will sing your praises for eternity as will their family."

 

[cruiseforever]

Can you show me any area which has more than 10mg of morphine or equivalent on standing order, or has standing order morphine+midazolam, or has ketamine or any sort of combination analgesia?

Brown has seen one area (Wake County) has entonox and it's a Paramedic (ALS) level skill for frig sake, back in 1975 our one week trained Elementary Ambulance Aid Officers could give entonox.

The service I work for is one. THe only limit we have on Morphine is 10 mg in a cardiac pt. When we hit 10 mg med control wants to know. Other wise 60 would be our limit because that is what we carry for Morphine. We can use Ketamine, Dilaudid, Versed. Used to carry Nitrous. It was a cost issue that led to that being pulled.

I am new to this site. But from what I have read, I think you are seeing Medics that are frustrated by systems that are holding them back. And they are more vocal due to their frustrations

 

[jjesusfreak01]

Can you show me any area which has more than 10mg of morphine or equivalent on standing order, or has standing order morphine+midazolam, or has ketamine or any sort of combination analgesia?

Brown has seen one area (Wake County) has entonox and it's a Paramedic (ALS) level skill for frig sake, back in 1975 our one week trained Elementary Ambulance Aid Officers could give entonox.

We have Versed (5mg max), Morphine (20mg max, except for burn patients), and Fentanyl (200mcg max) here in Wake County. Although NOX is in the protocols, I haven't ever seen it on a truck.

These are all standing orders...

 

[Melbourne MICA]

Cruel and unusual punishment.....

The philosophy on MICA here re analgesia is; if the patient still needs it they keep getting it and we have virtually no limit beyond common sense and the patients vitals ( and reasonable interpretation of guidelines.

I think the context of situations where you are providing narcotic or other IV analgesia does matter though. Multi-trauma patients come to mind - this is where the midaz/narcotic combination is risky. Whilst I have never seen Morph/Fentanyl trash the pts BP when they have genuine severe pain, Midaz will certainly do it. Not a good idea when you want to RSI or have other perfusion sensitive situations.

MM

 

[MrBrown]

The philosophy on MICA here re analgesia is; if the patient still needs it they keep getting it and we have virtually no limit beyond common sense and the patients vitals ( and reasonable interpretation of guidelines.

I think the context of situations where you are providing narcotic or other IV analgesia does matter though. Multi-trauma patients come to mind - this is where the midaz/narcotic combination is risky. Whilst I have never seen Morph/Fentanyl trash the pts BP when they have genuine severe pain, Midaz will certainly do it. Not a good idea when you want to RSI or have other perfusion sensitive situations.

MM

That is why we have ketamine now, provides profound analgesia and amnesia (in large enough doses for amnestic properties) with a very low haemodynamic risk.

Is partic good for shocked patients

 

[Veneficus]

Narcs don't scare me, we have Narcan. Amiodarone and Lidocaine in a conscious patient? Yeah, that scares me.

If I could just offer some perspective that night save yor patients a lot of grief?

If you induce the side effects of narcotics, it is much more humane to control ventilation and BP support than it is to acutely reverse them with narcan.

The patient was in enough pain for you to do something about it in your clinical judgement. If you acutely reverse it you will eleiminate all analgesia and then alternatives which usually are not always available in the ED must be used.

That basically means that you put your patient in irretractable pain until the narcan wears off. Once somebody "OD's" on medically administered narcs, every person after will be hesitant to give them any for quite a while.

 

[Shishkabob]

I knew that already, vene, and am just fine supporting ventilation on a narcotic overdose.


My point was, of necessary I could reverse a narcotic. I cant reverse an anti-arrythmic.

 

[Smash]

That is why we have ketamine now, provides profound analgesia and amnesia (in large enough doses for amnestic properties) with a very low haemodynamic risk.

Is partic good for shocked patients

Ketamine is indeed the nuts of the duck

 

[MrBrown]

Ketamine is indeed the nuts of the duck

Brown thought there was much kerfuffel about ketamine over your way?

Queensland only have it for fracture management (although this is where its very useful) we have it for "severe pain unresponsive to morphine" which is not defined but is mostly pacing, burns, fractures and suchlike as well as RSI.

Brown seems to remember something about MAS wanting another eleventybillion dollars for having it.

 

[Smash]

Brown thought there was much kerfuffel about ketamine over your way?

Queensland only have it for fracture management (although this is where its very useful) we have it for "severe pain unresponsive to morphine" which is not defined but is mostly pacing, burns, fractures and suchlike as well as RSI.

Brown seems to remember something about MAS wanting another eleventybillion dollars for having it.

No kerfuffle, it's just that only the whirlybird types have it, not everyone else. There is currently kerfuffle over research and what it is worth to the community, and what we should be getting in return. The RSI study got a few backs up as it showed a very significant reduction in cost to the community, improved outcomes for the patients and was a significant advance in work-practice for the road MICA, but the service (govt) said that it was not worth anything to anyone and would not increase our pay as a result.
All we want is to be recognised for the value we provide. And maybe to not be the worst paid ambos in the country!

EDIT: Sorry, there may be some kerfuffle from higher up the chain, I have heard second, third, fourth hand that they are worried about the potential for abuse of ketamine Doesn't stop them giving us all rubber stoppered 300mcg/ml fentanyl vials though!

 

[MrBrown]

You could always go work in WA or NT ....... no?

 

[johnrsemt]

I thought the comment by someone on this thread about his goal to cut pain from 10 to 5 was interesting: why? Why not make the pain go away?

My old area Medical Directors attitude was if the pain is a stubbed toe, and over 3/10 it had better be 0/10 when they get to the ED.

One of my old supervisors used to go to Med Director about me, almost quarterly because of my pain management: at one point the MD told me that I was giving out more pain meds than the next three medics combined at my company. He challenged me to increase my usage til I was giving more than ALL of the other medics at the company. I came close a few times, I think the MD was trying to get the manager to have a CVA.

 

[Shishkabob]

I thought the comment by someone on this thread about his goal to cut pain from 10 to 5 was interesting: why? Why not make the pain go away?

I said I make it a goal to cut in ATLEAST half, ie 10 to a 5, 8 to a 4, etc. If more, fantastic, but I'm not one to go "I gave you 100mcg of Fent, I don't care if it's still an 8"


But I'm also not going to completely snow my patient if they are comfortable.

 

[usalsfyre]

I agree, my goal is to get a patient to a "comfortable" level. Zero is ideal, but other factors come into play.