Pain management

[Rialaigh]

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..

The local ER has a chronic pain policy now. ER physicians are not allowed to prescribe or give narcotics to frequent fliers deemed pain seekers without OBVIOUS cause of pain. This was brought down from the state level to implement at many hospitals to try and curb frequent fliers from tying up resources. Now patients are explained that they can come back every day for the next week but no physician in the ER will give them a narcotic.

I don't know of a single EMS agency in my area that carries anything other than morphine and fent. I would be all over giving everyone some sort of pain management if we could have some non narcotic alternatives.


Also as to the comment about using number of visits or number of calls as part of your assessment. It does not replace a good physical assessment but frankly I consider it to be one of the most important parts of a history. If the patient is complaining about flank pain, and I know they have called EMS 30 times for this complaint and the ER has never found a kidney stone...I am betting the chances of a kidney stone now are pretty slim....the chances of a real emergency (while still possible) are even slimmer...

 

[Carlos Danger]

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?

Because this discussion seems to be about whether or not analgesia is really indicated at all in the patients in question.

And if analgesia isn't necessary because you suspect that the patient is faking or whatever, then a non-narcotic drug is no more appropriate than a narcotic one.

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.

I don't know about that. I think the reason those non-narcotic analgesics are pretty uncommonly used in EMS is because they just aren't great drugs for EMS use.

They aren't suitable as sole agents severe pain, which is what we are most concerned about in EMS. In some cases they can only be administered PO, which is a clear disadvantage or contraindication in many situations. They take a very long time to reach peak-effect, even in the IV forms. And finally, a good argument can be made that in a sick patient, these drugs carry even more considerations and implications than opioids do.

I'm not saying that non-narcotic analgesics have no place in EMS, just that the situations where they are a better choice than opioids are very few. If that weren't the case, they would be more widely used.

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."

Personally, I think that is a reasonable sentiment. Severe pain is an emergency, but lesser pain is not. I don't think it's practical for necessary or possible for EMS to try to make everyone pain-free. With a typical transport time of 30 minutes or so, your patient would probably already be in the ED for quite a while before the non-narcotic even reached full effect.

 

[jwk]

Further, few paramedics actually delve into chronic pain, ect, and when they do it's an excuse to WITHHOLD meds rather than administer.

Chronic pain is really not an EMS issue.

Chronic pain patients can be on any number or combination of medications to treat their chronic pain. There are a lot of creative combinations out there with non-narcotic meds such as pregabalin, gabapentin, and some anti-seizure meds that interrupt some pain perception pathways. In addition, there are those who are using long acting narcotics including fentanyl patches and impressive doses of oxycontin. These are not patients that need a paramedic second guessing the pain management plan already in place for a given patient and adding narcotics to the mix just because the patient says they're hurting.

 

[triemal04]

In other words, it's more of a philosophical difference, which is why it warrants discussion. There's not much argument over the pharmacological points.

It's not a philosophical difference at all. Either people are willing and able to perform their job as a medical provider, which means determening what treatements, if any, are needed before giving them...or they aren't. Some people we see, no matter what the problem is, need immediate treatement...some don't. Some need things we don't carry...some do. That determination needs to be made for every patient, every time.

There is a reason even ED physicians are are held accountable to answer when A patient has not been given analgesia in the ED In a set time period.

Yes, it's called patient satisfactions surverys (PG scores) and profits; don't fool yourself into thinking that is being done soley for altruistic reasons.

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...

This is something that everyone needs to be very careful with; pt's with chronic, longstanding pain problems. This is where having them treated by a reputable pain specialist is vital, and where sitting down with one could pay off for a lot of paramedics. The goal isn't neccasarily to make the patient "pain free" but to get them to a point where they can go about their daily activities of living without issue and function normally; ie to lead a regular life. If someone is still fulfilling all those things despite complaining of increased pain, an immediate dose of anything likely is not needed, and may not be in the patient's best interest.

This topic, like so many others is pointless. There are far to many people who think that they have "been there done that," know everything, and let singular personal experiences reflect on their view of other providers and view of what is appropriate.

 

[Leal271]

Unforunately if you have the belief someone is a "drug seeker" you may not do whats best for the PATIENT. Do a good assessment, and treat your patient.

 

[coolidge]

prescription monitoring program (PMP)

The appropriate emergency staff practitioner can access your state's prescriptiom monitoring program (PMP) data bank.
The data bank will provide a historical picture of controlled substance prescriptions acquisitions.
Also, some hospitals, and several states, are developing a system of sharing medical histories, which identify patient's history of ER usage, etc.

 

[TheLocalMedic]