Pain Control

[marineman]

[usalsfyre's head explodes]

Yep, that quote is probably 50% of the problem. The other 50% is "He's a drug seeker and I don't want to reward his behavior/make him call more". Makes me want break the medic in question's arm and call him a seeker. As to this quote... Isn't it his JOB to investigate why morphine isn't being used appropriately, educate/discipline those who aren't practicing good medicine, and change protocols/formulary as needed to ensure best practices?!? Sounds pretty lazy on his part.

[usalsfyre attempts to find all the pieces of his head and put them back together, Humpty Dumpty style]

I agree with you 100% however our medical director is honestly as hands off as possible which is complete BS if you ask me but nobody asks me. I wish I could post our protocols for all to view how bad they are but the only place they are online is on our employee website and a login is required. The other day I compared our protocol book from 1997 to our newest one revised last month and only 2 protocols have changed.

We are now doing "CCR" resuscitation of PNB's meaning we put a nonrebreather on and place an OPA before intubation rather than trying to bag them with an OPA. Other protocol is we have now adopted the hospitals code STEMI protocol and added Plavix.

this ends the off topic rant, give more pain meds.

 

[NomadicMedic]

this ends the off topic rant, give more pain meds.

Not more pain meds ... appropriate pain meds, in appropriate dosages for the patient. That's the key.

Simply giving 2-4mg of Morphine to a patient with a traumatic injury doesn't do anything for anybody.

Being aware of the patient's discomfort and effectively managing that pain is what makes you a proficient caregiver that will be ultimately more respected by the other professionals you'll deal with. When I bring a trauma patient in to the ED and can clearly describe how I managed the patient's pain from 10/10 to zero (or as close as possible) through the judicious use of opiates and benzos, I'm routinely thanked by the docs for being aggressive with my pain management.

If I'm ever pulled into farm equipment or take a high speed spill off a motorcycle, I just hope the paramedic that responds isn't afraid to open his narc box and deal out the stuff. We have the ability to manage pain. When we don't, it's unforgivable.

 

[rhan101277]

Administered 15mg of Toradol IVP for RLQ pain 10/10, w/ guarding, gramacing. Pt had trouble urinating x3 days, no fever, no kidney stone hx, but I suspected kidney stones. Had to call and get orders but it is better than nothing. They don't want us bring in abdominal pain patients who are snowed, makes the doctors assessment more difficult.

It is also noteworthy that other medics won't even call for situations such as these, therefore no drug is given.

If it is like an obvious injury then I am captain pain management.

 

[usalsfyre]

They don't want us bring in abdominal pain patients who are snowed, makes the doctors assessment more difficult.

Simple solution, don't snow your patients. It's certainly possible to administer appropriate pain relief without snowing your patient under. If they still give you trouble (the whole "trained surgical hands" crap) show them any number of studies that state analgesia makes no difference in assessment accuracy.

 

[Shishkabob]

Or bring up the fact that every time I have ever been in a crap ton of pain, I could still describe what it felt like and exactly where it was even after the pain was gone. Heck, I can still describe the two times I dislocated my kneecap... and those were 4 and 6 years ago.



If they still give you trouble, remind them that a drug exist called "Narcan". They obviously don't care about pain control, so it won't matter that they can't give narcotics afterward.

 

[Smash]

They don't want us bring in abdominal pain patients who are snowed, makes the doctors assessment more difficult.

Noooooooooooo!!!! *Smash's head explodes*

Less difficult! It makes assessment less difficult! And the patient happier!

Damn you Mr Cope!

 

[rhan101277]

Noooooooooooo!!!! *Smash's head explodes*

Less difficult! It makes assessment less difficult! And the patient happier!

Damn you Mr Cope!

Yeah this is just for abdominal pain, since you are never certain if it is a bleed or not. Unless it is obvious.

 

[NomadicMedic]

Yeah this is just for abdominal pain, since you are never certain if it is a bleed or not. Unless it is obvious.

Wait, I'm sorry... you can't treat abdominal pain at all? Even if the patient is hemodynamically stable?

It's been shown in several papers (I'll post some cites in a few) that pre-hospital analgesia for abdominal pain facilitates the ED examination and reduces patient's anxiety.

 

[usalsfyre]

Yeah this is just for abdominal pain, since you are never certain if it is a bleed or not. Unless it is obvious.

What does hemorrhage in the abdominal cavity have to do with withholding pain meds? Don't you think peritoneal irritation hurts?

 

[Veneficus]

They don't want us bring in abdominal pain patients who are snowed, makes the doctors assessment more difficult.

This is absolutely false.

I don't know who started saying this or when.

The earliest account of witholding pain medication for abdominal pain I can find is from a surgical practice dating back to the early 1900's.

The idea behind it was that because visceral pain is poorly localized, when the peritoneum which does have local stretch receptors becomes inflammed, then the origin of the insult could be deduced.

Unfortunately it wasn't very accurate.

Fortunately, our understaning of pathology and visceral pain mapping has gotten considerably better.

As smash pointed out, controlling abdominal pain actually makes the physical exam easier and more accurate.

I have seen a US trauma surgeon withold pain meds on an abdominal GSW to determine the level of post surgical bleeding was increasing and not properly draining from the tube.

However, considering that the problem could easily be solved by serial ultrasound, I do not advocate repeating that "test."

In defense of the surgeon, because the use of ultrasound is dependant on user skill and not totally objective, its usage in the US is considerably less than in other places. Mostly out of fear of litigation, I am told.

Like any skill, lack of usuage diminishes the skill even further.

The lack of use also equates to lack of training opportunities.

In my book, fear of litigation is not reason enough to leave a patient in pain.

As one of my best preceptors likes to say:

"You would never sue your friend, but would gladly sue your enemy."

I would think making the patient feel better by properly managing pain would make them less likely to sue than more. Even if there were complications to the treatment.

Some people sue no matter what, why worry about it?

 

[rhan101277]

I actually heard the RN say to the patient that they didn't want to give him to much morphine because the doc didn't know what he was treating. Hypotension is a side effect of morphine admin. You don't want to give it to abdominal pain that you determine might possibly be descending Aortic dissection.

But this case I had was kidney stones I thought, but field providers can be wrong. We don't have all the fancy tests doctors have, nor do we have the education or experience.

Don't get me wrong, I am big on pain management. A thorough assessment is required though.

 

[Veneficus]

I actually heard the RN say to the patient that they didn't want to give him to much morphine because the doc didn't know what he was treating. Hypotension is a side effect of morphine admin. You don't want to give it to abdominal pain that you determine might possibly be descending Aortic dissection.

But this case I had was kidney stones I thought, but field providers can be wrong. We don't have all the fancy tests doctors have, nor do we have the education or experience.

Don't get me wrong, I am big on pain management. A thorough assessment is required though.

You don't want to give it for billiary tree pathology either as the morphine causes contraction of the sphincter of oddi.

But all of that just demonstrates the importance of physical exam and history skills.

"What if" is poor medicine.

 

[MrBrown]

We are taught it is unethical to withhold pain medication, and it is!

*Brown calls the MAS Metro Clinician for advice on how to treat Humpty Dumpty syndrome

 

[Veneficus]

We are taught it is unethical to withhold pain medication, and it is!

*Brown calls the MAS Metro Clinician for advice on how to treat Humpty Dumpty syndrome

Just to point out, if you give mophine to a patient suffering from the pathology i described, it actually increases pain. (not to mention can potentially cause a perforation)

However, you guys down there have considerably more options than US EMS when it comes to pain management.

 

[rhan101277]

You don't want to give it for billiary tree pathology either as the morphine causes contraction of the sphincter of oddi.

But all of that just demonstrates the importance of physical exam and history skills.

"What if" is poor medicine.

How is "what if" poor medicine? You have to leave all your options open and try to narrow down what it is w/ physical exam and hx taking. You have to ask yourself what if it is this and I do this. We can't make a 100% diagnosis in the field we aren't doctors.

 

[Veneficus]

How is "what if" poor medicine? You have to leave all your options open and try to narrow down what it is w/ physical exam and hx taking. You have to ask yourself what if it is this and I do this. We can't make a 100% diagnosis in the field we aren't doctors.

Because if you worry about every "what if" you would end up doing nothing.

Unless you are only worried about the "what if's" you know about.

Nobody is asking you to diagnose 100% in the field. But from your own suspicion of renal stones, I don't think it is asking a lot to be able to narrow down the list of what might be wrong in the abdomen to the organ system involved.

 

[jwk]

You don't want to give it for billiary tree pathology either as the morphine causes contraction of the sphincter of oddi.

We give narcotics for these patients all the time - sphincter of oddi contraction is not something that always happens when a patient is given narcotics, and is actually relatively rare. I've seen it once in 30 years, and that patient's pain got better when we gave some Narcan. If nothing else, if you give some narcotics and their belly pain gets worse, it's at least somewhat diagnostic, or at least helps your differential.

 

[Veneficus]

We give narcotics for these patients all the time - sphincter of oddi contraction is not something that always happens when a patient is given narcotics, and is actually relatively rare. I've seen it once in 30 years, and that patient's pain got better when we gave some Narcan. If nothing else, if you give some narcotics and their belly pain gets worse, it's at least somewhat diagnostic, or at least helps your differential.

Could I ask you if you have some literature on this?

The most recent study I found was 2004, but that was out of China, so it is highly suspect.

The latest reliable one I could find was from 2001 from a hepato-biliary journal, which basically upheld meperidine over mophine.

I am always interested in finding things that go against conventional practice. Please if you could help with this particular topic?

 

[MrBrown]

Sorry Brown was referring to morphine in biliary pain, we are taught (and Brown has no independent evidence to support or refute the sphincter contraction theory, to PubMed!) that it is not contraindicated and unethical to withhold it.

Brown was also referring to withholding pain medicines in general.

 

[Veneficus]

Sorry Brown was referring to morphine in biliary pain, we are taught (and Brown has no independent evidence to support or refute the sphincter contraction theory, to PubMed!) that it is not contraindicated and unethical to withhold it.

Brown was also referring to withholding pain medicines in general.

We were specifically taught it was not to be used in biliary pain. Sometimes ad nauseum.

In fact it is specified in 2 of my texts. (but i have heard it constantly over the last year)

All of my pub med and google search this eveing on it turned up stuff that basically said it demonstratively caused contraction.

Here is the original pubmed study I found and the rest were listed from it.

http://www.ncbi.nlm.nih.gov/pubmed/11316181