Pain management

[epipusher]

These replies help to maintain my faith that the majority of providers are true professionals.

 

[FiremanMike]

... disregard this one..

 

[FiremanMike]

These replies help to maintain my faith that the majority of providers are true professionals.

Given your fervent argument towards pain control in this particular scenario, I can only assume that your somewhat vague statement here would indicate that you feel anyone who wouldn't give pain management to this patient would fall under the category of "not a true professional".

I would appreciate it if you could expand on that, as I feel that the rationale for not giving pain medication to this particular patient (barring no other assessment findings which weren't reported in the initial post) were solid and based on sound clinical judgement.

 

[Rialaigh]

Let me throw a wrench in this scenario.

In the state I work in we have to call for a physician to the radio to request to give narcotics, every time. The ER is a 36 bed ER staffed by two physicians and a PA, the physicians manage 30 of the beds. There are generally people in the waiting room and the ER is full from 11am to roughly 3am or later.

If I am calling for pain management and having to take a physicians time away from an already full and busy ER with average transport times of less than 20 minutes I am not real inclined to do that minor pain, non descript pain, and frequent fliers with repeat complaints.

Would having to call for online orders for all pain management change your concepts on who you would or wouldn't treat?

 

[chaz90]

Would having to call for online orders for all pain management change your concepts on who you would or wouldn't treat?

Ugh. What a horrific policy. This actually wouldn't change what I did though. On the contrary, I would hope that my (and others like me) frequent calls for pain control orders would gradually convince someone higher up that this protocol needed to be changed. If many medics are reluctant to call in for orders, there may not seem to be an impetus to change a hopelessly outdated policy such as this.

 

[Christopher]

Would having to call for online orders for all pain management change your concepts on who you would or wouldn't treat?

The literature shows that any barrier (money, paperwork, etc) to a treatment reduces the usage of the treatment. This is well known to many other industries/fields.

Here is a gem from a protocol, which you may find interesting in comparison to your system:

"In all protocols, the instructions which state "notify destination or contact medical control" is satisfied in our system by contacting the receiving hospital at the appropriate time. We have no restriction to contact medical control prior to administering any treatments in subsequent boxes. Obviously, if you need to contact medical control at any time for patients with unusual presentations, high risk refusals, or any other unusual circumstances, please continue to do so."

 

[usalsfyre]

Let me throw a wrench in this scenario.

In the state I work in we have to call for a physician to the radio to request to give narcotics, every time. The ER is a 36 bed ER staffed by two physicians and a PA, the physicians manage 30 of the beds. There are generally people in the waiting room and the ER is full from 11am to roughly 3am or later.

If I am calling for pain management and having to take a physicians time away from an already full and busy ER with average transport times of less than 20 minutes I am not real inclined to do that minor pain, non descript pain, and frequent fliers with repeat complaints.

Would having to call for online orders for all pain management change your concepts on who you would or wouldn't treat?

I'll say it again...your obligation is to your CURRENT patient...not anyone else's or any future patients. "Oh I'm taking up valuable time" is weak.

 

[usalsfyre]

Furthermore, to draw a conclusion that providers who would not universally provide pain medication are judgmental is in and of itself a judgmental position.

Yep it absolutely is. There's NOTHING wrong with being judgmental no matter what the current PC theory is, judgement exist to aid in decision making. Part of my JOB is to be judgmental. What's not ok is withholding an indicated medication based on demographic (age, race, weight, gender, socioeconomic status, frequency of contact, ect).

To blanketly state that you give everyone pain medication that present with a complaint of pain is the same as saying you give nitro to anyone with chest pain, ignoring all mitigating factors.

While I don't go down the cardiac treatment pathway for every CP patient all of them get a 12 lead EKG because it's indicated and benign. Despite what medic school TRIES to convince us of, narcs are one of the more benign drugs we carry.

Perhaps it's because we carry several non-narcotic options I don't see why you can't medicate this guy in some way.

 

[FiremanMike]

Yep it absolutely is. There's NOTHING wrong with being judgmental no matter what the current PC theory is, judgement exist to aid in decision making. Part of my JOB is to be judgmental. What's not ok is withholding an indicated medication based on demographic (age, race, weight, gender, socioeconomic status, frequency of contact, ect).


While I don't go down the cardiac treatment pathway for every CP patient all of them get a 12 lead EKG because it's indicated and benign. Despite what medic school TRIES to convince us of, narcs are one of the more benign drugs we carry.

Perhaps it's because we carry several non-narcotic options I don't see why you can't medicate this guy in some way.

I believe I pretty clearly spelled out why I wouldn't give pain medication to this patient, and the only demographic considered by your list (frequency of contact) was far down the list and far less important than clinical assessment findings. I was pretty clear on that..

12 lead is an assessment tool, morphine and nitro are treatments. I'm not sure I understand your comparison?

 

[VFlutter]

1-- if a guy that is 30 looks 70 odds are drugs aged him:censored:

Oh really? You obviously have not taken care of many chronically ill patients. When I have a young cachectic patient I do not assume they are a drug addict.

 

[Brandon O]

But when someone is sitting in front of me and tells me they are in pain, I can neither rule in or out the fact they are in fact experiencing pain. All I have is their word.

Right. So you sort of have to decide ahead of time -- and even if you don't sit down and do it explicitly, you are still deciding -- whether, by and large and within reason, you're going to trust their word or you're not. Because neither before, during, or after are you likely to get objective evidence to "confirm" someone's pain.

This has nothing to do with decisions that can be made based on objective findings. But usually pain isn't like that, unless we manage to fool ourselves into thinking we're smarter than we are ("bah, people don't look like that when they're hurting"). So that decision won't be based on the patient, it'll be based on the kind of provider you want to be. Do you want your sin to be giving pills to addicts or standing by while someone suffers?

I would prefer to lean toward the former, but I'm actually not arguing that everyone should agree. I am saying that we should acknowledge we're making that choice, though, and it's based on nothing but our personal ethics and worldview.

 

[Akulahawk]

Right. So you sort of have to decide ahead of time -- and even if you don't sit down and do it explicitly, you are still deciding -- whether, by and large and within reason, you're going to trust their word or you're not. Because neither before, during, or after are you likely to get objective evidence to "confirm" someone's pain.

This has nothing to do with decisions that can be made based on objective findings. But usually pain isn't like that, unless we manage to fool ourselves into thinking we're smarter than we are ("bah, people don't look like that when they're hurting"). So that decision won't be based on the patient, it'll be based on the kind of provider you want to be. Do you want your sin to be giving pills to addicts or standing by while someone suffers?

I would prefer to lean toward the former, but I'm actually not arguing that everyone should agree. I am saying that we should acknowledge we're making that choice, though, and it's based on nothing but our personal ethics and worldview.

What a great point you brought up!

It's amazing what happens when you find someone who is in sickle-cell crisis who says they're in 10/10 pain and they're sitting there playing video games... you think this is someone that's not in pain because they don't "look" like they're in pain. It's not that they aren't, rather they have lived with it for so long that they don't display it like the rest of us normally would. A "comfortable level of pain" for that person might be a 6/10.

 

[Rialaigh]

If anyone is wondering it is SC state law (or SC state EMS protocol) that you cannot give a controlled substance (morphine, nubaine) without online medical control. It is not an agency problem, it is statewide.

Yep it absolutely is. There's NOTHING wrong with being judgmental no matter what the current PC theory is, judgement exist to aid in decision making. Part of my JOB is to be judgmental. What's not ok is withholding an indicated medication based on demographic (age, race, weight, gender, socioeconomic status, frequency of contact, ect).


While I don't go down the cardiac treatment pathway for every CP patient all of them get a 12 lead EKG because it's indicated and benign. Despite what medic school TRIES to convince us of, narcs are one of the more benign drugs we carry.

Perhaps it's because we carry several non-narcotic options I don't see why you can't medicate this guy in some way.

Demographic is a very reliable tool to add to the box that helps us determine the seriousness of a problem or if a patient is "sick" or not.

All 6 of the criteria that you listed for demographics do make a difference in the frequency of occurrence and presentation for various diseases. I could give you examples backed with studies for all of those. Demographics need to be a part of your decision making process. I can give you reasons to give meds and reason to withhold meds based on demographics.

I'll say it again...your obligation is to your CURRENT patient...not anyone else's or any future patients. "Oh I'm taking up valuable time" is weak.

This is a whole different discussion but when you talk about an ER physician or a ER nurse their job is constant triage and treatment of dozens of patients at a time. I am not going to be inconsiderate of that ER physicians time by taking his time away from his other patients unless my patient really needs pain medication. The same reason I don't demand my "toothache" patient go to a code room immediately instead of triage...it may be my only patient currently but it is one of 50-80 patients in the ER at the time I bring them.

 

[Carlos Danger]

Right. So you sort of have to decide ahead of time -- and even if you don't sit down and do it explicitly, you are still deciding -- whether, by and large and within reason, you're going to trust their word or you're not. Because neither before, during, or after are you likely to get objective evidence to "confirm" someone's pain.

This has nothing to do with decisions that can be made based on objective findings. But usually pain isn't like that, unless we manage to fool ourselves into thinking we're smarter than we are ("bah, people don't look like that when they're hurting").

So that decision won't be based on the patient, it'll be based on the kind of provider you want to be. Do you want your sin to be giving pills to addicts or standing by while someone suffers?

I would prefer to lean toward the former, but I'm actually not arguing that everyone should agree. I am saying that we should acknowledge we're making that choice, though, and it's based on nothing but our personal ethics and worldview.

Excellent, excellent, excellent points. Pretty much sums up this entire thread, if you ask me.

Obviously there is always discretion involved - and I'm not saying I would have medicated the patient in the OP's scenario - but anyone who refuses to give analgesia without "objective evidence" of pain will absolutely be guilty of under-treating for pain.

 

[usalsfyre]

I believe I pretty clearly spelled out why I wouldn't give pain medication to this patient, and the only demographic considered by your list (frequency of contact) was far down the list and far less important than clinical assessment findings. I was pretty clear on that..

12 lead is an assessment tool, morphine and nitro are treatments. I'm not sure I understand your comparison?

Ok, a better comparison would be I administer the vast majority of non-traumatic CP patients ASA (assuming no overt contraindications) regardless of suspected origin based on the fact there's little chance of harm and the benefit is relatively great. I think you'll find it's not unusual in EM.

What's your risk of using an indicated medication? What's your chance if harm? Why do so many organizations in healthcare make pain management a benchmark? Why do EM docs typically discharge someone with a script for meds EVEN IF it's not a narcotic option.

I'm not advocating 4mgs of Dilaudid for everyone. But why is 500 of APAP, 30 of ketorolac or 400 of ibuprofen such a problem if the patient is complaining? The "physical assessments" you use are not considered reliable by anyone else...what makes you special?

 

[usalsfyre]

If anyone is wondering it is SC state law (or SC state EMS protocol) that you cannot give a controlled substance (morphine, nubaine) without online medical control. It is not an agency problem, it is statewide.



Demographic is a very reliable tool to add to the box that helps us determine the seriousness of a problem or if a patient is "sick" or not.

All 6 of the criteria that you listed for demographics do make a difference in the frequency of occurrence and presentation for various diseases. I could give you examples backed with studies for all of those. Demographics need to be a part of your decision making process. I can give you reasons to give meds and reason to withhold meds based on demographics.




This is a whole different discussion but when you talk about an ER physician or a ER nurse their job is constant triage and treatment of dozens of patients at a time. I am not going to be inconsiderate of that ER physicians time by taking his time away from his other patients unless my patient really needs pain medication. The same reason I don't demand my "toothache" patient go to a code room immediately instead of triage...it may be my only patient currently but it is one of 50-80 patients in the ER at the time I bring them.

I have a background in the ED as well as on an EMS unit. I get flow. I get triage, to the point I've DONE ED triage before. So I'll say this.

You are not an EM doc, or ED nurse. You are a paramedic and therefore have an ethical obligation to ONE patient. ONE. Other patients in the ED or the ED staff's time are not your concern. If I heard this excuse for withholding analgesia out of any of my providers my response would be in writing and stay in their file for a year. Flow and dispo are vitally important and we should do everything we can to assist it, but not at the expense of the patient you are responsible for.

All of those demographic factors should play into assessment except for one. If you're basing ANYTHING on number of contacts you're an idiot who's going to get bit in the butt by it. You will very, very lucky if complacency causes a non-fatal event and lucky if it's only fatal for the patient. DO NOT get complacent in any portion of this job.

As for the others, yes they play in but not ONE of those holds any weight for withholding meds. Detecting atypical presentation, recognizing tendency for being stoic..maybe. But not withholding.

 

[FiremanMike]

Ok, a better comparison would be I administer the vast majority of non-traumatic CP patients ASA (assuming no overt contraindications) regardless of suspected origin based on the fact there's little chance of harm and the benefit is relatively great. I think you'll find it's not unusual in EM.

What's your risk of using an indicated medication? What's your chance if harm? Why do so many organizations in healthcare make pain management a benchmark? Why do EM docs typically discharge someone with a script for meds EVEN IF it's not a narcotic option.

I'm not advocating 4mgs of Dilaudid for everyone. But why is 500 of APAP, 30 of ketorolac or 400 of ibuprofen such a problem if the patient is complaining? The "physical assessments" you use are not considered reliable by anyone else...what makes you special?

My unmentioned physical assessments aren't considered reliable by anyone else, or the physical assessments that I've not described aren't considered reliable by those here who advocate throwing narcotics at everyone despite consideration of the presence (or lack thereof) of physical findings and without considering the presence (or lack thereof) of mitigating factors.

There have been so many special circumstances thrown about throughout this thread that aren't relevant to the original situation, and when present would definitely alter my decision making product. People continue to add it snippets of things that could be wrong with this patient, and are ignoring the notion that those might be discovered and considered during the assessment. Had they been mentioned as assessment findings during the original post, would have altered the decision making path. Because they weren't, and this patient is imaginary, it's safe to assume they are negative findings and warrant no further consideration.

Additionally, you made a previous statement that the patient at hand is the only one worthy of consideration at the moment and this notion is patently false in healthcare of 2013. Does a chronic pain patient really need to be transported by EMS to the ED, saturating those resources daily, or would society as a whole be best served if we could assist them in getting to a chronic pain doc who can more appropriately manage them? Don't jump to the conclusion that I refuse to transport pain patients, but I have been making efforts lately to help patients reach more appropriate means of treatment as opposed to just blindly taking everyone to the ER. We're now talking about the community paramedic ideas that are floating around, and if what I'm hearing is true, they will be the norm very soon. ***ETA - I don't use this thought process all inclusively wheen considering pain management, and may not be totally relevant to the discussion of pain control for this patient, but it needed to be said.***

Finally, it may interest you to note that the local ERs here are actually being much more stringent about treating nonspecific, non verifiable pain, but then again I am very fortunate to work in a progressive area..

 

[Aidey]

But why is 500 of APAP, 30 of ketorolac or 400 of ibuprofen such a problem if the patient is complaining? The "physical assessments" you use are not considered reliable by anyone else...what makes you special?

I'm going to go with because probably less than 5% of EMS agencies in the US carry even one of those options.

Is that right? No, it isn't. But is that part of the reason that pain complaints are under-medicated? Hell yes.

 

[Christopher]

I'm going to go with because probably less than 5% of EMS agencies in the US carry even one of those options.

Is that right? No, it isn't. But is that part of the reason that pain complaints are under-medicated? Hell yes.

If my podunk USA fire department has all 3 of those, anybody can.

Hell my industrial fire brigade carries all but the toradol (and if we were EMT-I level we'd carry and give it...).

 

[chaz90]

If my podunk USA fire department has all 3 of those, anybody can.

Hell my industrial fire brigade carries all but the toradol (and if we were EMT-I level we'd carry and give it...).

Agreed, but that doesn't seem to be the consensus of many medical directors. Protocol is statewide here and decided by a committee that makes significant changes only by a near act of God as far as I can tell. I'm not defending this thought, but I think many who write protocols figure "If the pain isn't severe enough for opioids, it can wait until they arrive at the ED."