Pain Management

[paramedix]

Always remember the basics...

ABC...

Oxygen was found to be a good 'pain reliever', but all of our Basic Ambulance Assistants are trained and qualified to use Entonox. The flaw in this, however, that in my whole career in the private ambulance service, I have not seen Entonox once on any of our vehicles. Not even in government.

I do agree that if you want to give drugs, get the qualification. A good way to start. In South Africa we have recently introduced a new qualification called the ECT.

Candidates that qualify ECT can prescribe and administer certain drugs at a basic level.

Maybe in your country you can do a module for certain drugs and qualify at the end having it as a skill? Only our ALS have modules for newly introduced drugs.

 

[TheMowingMonk]

well i guess it varies by region having to be an EMT before becoming a paramedic. Ive been reasearching paramedic schools in my area and from what ive found all of them require you have at least one year experiance with logged hours as an EMT before you can even start training to be a paramedic.

 

[Sapphyre]

The state of California (as you're discovering) is one of those that are requiring that you actually work as an EMT for at least a year before applying to medic school. Something I found out recently as well.

 

[Epi-do]

Much pain can be alleviated by BLS measures before ALS interventions. How many paramedics have gone straight to Morphine for a fracture before making sure the affected part was properly padded, splinted, elevated, padded some more in the ambulance, and iced? More than one, I assure you. BLS before ALS is good!

Nope not really, little to none. Hence the reason all EMS units should be ALS. Let me fracture your arm, you choose which you would rather have. Cold pack and splints or analgesics then the usual splint and cold packs?

Rid, while I typically agree with you, I have to disagree with you here. Speaking strictly from the perspective of someone who has had 8 broken bones throughout my childhood and young adult life, not all of them were painful enough for me to require pain meds.

I had one break that it was almost a week before I went to the doctor for. It was a clean break that was apparent on x-ray, but due to circumstances surrounding the injury and the location of the break, it honestly wasn't painful. It was achy and sore, but definately not painful.

On the other hand, I have had breaks that I would have given anything for some pain relief. The broken leg I aquired while skating, or the cracked rib and chipped vertebrea caused by falling off a horse were definately painful enough to warrent pain meds. Of course, my mother, the RN, decided to take me to the ER herself after the broken leg and I had a friend take me there after the spill off the horse. I wasn't offered pain meds after arriving at the ER in either instance, but both were well over 15 years ago.

I do believe that in some instances proper splinting and padding can be effective, however the pain meds should be available for those who need it. Everyone has a different pain threshold and given two patients with identical histories and injuries, one may want pain meds while the other may not. I think ultimately it comes down to how the patient is feeling and not "merely" the fact that they have a broken bone or some other musculoskeletal injury.

 

[triemal04]

Rid, while I typically agree with you, I have to disagree with you here. Speaking strictly from the perspective of someone who has had 8 broken bones throughout my childhood and young adult life, not all of them were painful enough for me to require pain meds.

I had one break that it was almost a week before I went to the doctor for. It was a clean break that was apparent on x-ray, but due to circumstances surrounding the injury and the location of the break, it honestly wasn't painful. It was achy and sore, but definately not painful.

On the other hand, I have had breaks that I would have given anything for some pain relief. The broken leg I aquired while skating, or the cracked rib and chipped vertebrea caused by falling off a horse were definately painful enough to warrent pain meds. Of course, my mother, the RN, decided to take me to the ER herself after the broken leg and I had a friend take me there after the spill off the horse. I wasn't offered pain meds after arriving at the ER in either instance, but both were well over 15 years ago.

I do believe that in some instances proper splinting and padding can be effective, however the pain meds should be available for those who need it. Everyone has a different pain threshold and given two patients with identical histories and injuries, one may want pain meds while the other may not. I think ultimately it comes down to how the patient is feeling and not "merely" the fact that they have a broken bone or some other musculoskeletal injury.

So what exactly are you trying to say? That some people will need drugs for pain and some won't? That some injuries will and some won't? Ok. But that's nothing new and doesn't change anything. Don't you think that if someone does need something to treat their pain they should be able to get it? If splinting doesn't work (or the movement makes things worse...also common) what should happen next? Think of it like this...many, many "chest pain" type calls are not cardiac related, but it's still appropriate to have the right personell there in case they are. Same issue when here.

Just because someone has the ability to do something, give something, or have something done doesn't mean that they will everytime, or that it is appropriate to do it everytime.

People seem to forget that all to often.

 

[Ridryder911]

Albeit you were lucky on such events and should be considered unusual, most people will inform you fractures are painful (hence one of the symptoms). Again, common sense comes back into play. Assessment of not just physical but pain management of course if the threshold is No Pain no analgesics, but one has to be careful of break through pain. I have found (as well as experts in pain management) to provide analgesics before such an event. It is then hard to manage pain.

Splinting is a give me. Really, proper padding and appropriate type is not usually a difficult maneuver (open ones can be difficult). Again, that should be a routine procedure and not have to be emphasized.

R/r 911

 

[Epi-do]

So what exactly are you trying to say? That some people will need drugs for pain and some won't? That some injuries will and some won't? Ok. But that's nothing new and doesn't change anything. Don't you think that if someone does need something to treat their pain they should be able to get it? If splinting doesn't work (or the movement makes things worse...also common) what should happen next? Think of it like this...many, many "chest pain" type calls are not cardiac related, but it's still appropriate to have the right personell there in case they are. Same issue when here.

Just because someone has the ability to do something, give something, or have something done doesn't mean that they will everytime, or that it is appropriate to do it everytime.

People seem to forget that all to often.

I definately wasn't trying to say that someone should not receive a specific treatment if they needed it. On the other hand, I don't believe with the majority of injured people analgesia should be one of the first things that come to mind. I think it is more important to assess the situation first. Then, if warrented, by all means consider if medication for pain management is appropriate.

After reading Rid's latest response, as well as re-reading what was previously written, I just wasn't quite "getting" what he was saying. Lack of sleep, a big pharm test, and everything else that goes along with medic class, and life in general, was catching up with me. With my test behind me, and plenty of sleep, I am able to make more sense of what was being said. It happens to all of us. The other night, it was just my turn to miss the point.

 

[MedicDoug]

Nothing personal Doug, but I am shocked a Paramedic would even state such.

No offense taken, Ridryder. Let me try to make my position completely clear. I believe that we fail all too often in the prehospital environment to properly manage pain. At the ALS level we should use EVERYTHING possible at our disposal to make the patient more comfortable, be it Morphine, Fentanyl (I wish!) as well as proper splinting, etc. Pain ceases to be diagnostic right after "Can you rate your pain on a scale....."
My point (which I haven't yet been able to make clear) is that the BLS part of fx management is just as important as pharmaceutical interventions, and is too often forgotten. Rest assured, if you break your arm or leg around here and I get to you first, there will be MS on board before you get moved. (providing, of course, you're not allergic to MS nor hypotensive!)

As for the "BLS before ALS"... around here we can have long response times, and we're sometimes frustrated by the BLS responders' lack of action before ALS arrives... "We were waiting for you to show up with your IV Dextrose so we didn't give oral glucose". I think it's a combination of timidity and probably a training issue. Both of which can be fixed, but it takes time.

 

[skyemt]

Much pain can be alleviated by BLS measures before ALS interventions. How many paramedics have gone straight to Morphine for a fracture before making sure the affected part was properly padded, splinted, elevated, padded some more in the ambulance, and iced? More than one, I assure you. BLS before ALS is good!

No offense taken, Ridryder. Let me try to make my position completely clear. I believe that we fail all too often in the prehospital environment to properly manage pain. At the ALS level we should use EVERYTHING possible at our disposal to make the patient more comfortable, be it Morphine, Fentanyl (I wish!) as well as proper splinting, etc. Pain ceases to be diagnostic right after "Can you rate your pain on a scale....."
My point (which I haven't yet been able to make clear) is that the BLS part of fx management is just as important as pharmaceutical interventions, and is too often forgotten. Rest assured, if you break your arm or leg around here and I get to you first, there will be MS on board before you get moved. (providing, of course, you're not allergic to MS nor hypotensive!)

As for the "BLS before ALS"... around here we can have long response times, and we're sometimes frustrated by the BLS responders' lack of action before ALS arrives... "We were waiting for you to show up with your IV Dextrose so we didn't give oral glucose". I think it's a combination of timidity and probably a training issue. Both of which can be fixed, but it takes time.

Doug, difficult to follow your point when you switch back and forth between two sides... in one post you criticize medics who "go straight for the morphine", and in the next post you say "there will be morphine on board before you get moved"...

which is it?

also, if your basics are "timid", that is an issue with your service, but has nothing to do with pain management on the EMT-B level...

i am having a hard time following what you are trying to say here...

 

[MedicDoug]

Yeah, I'm probably trying too hard... my point is that we don't do enough pain management in the field... regardless of resources available. We should use all of the resources at our disposal to make our patients comfortable, be it a well padded splint correctly applied, oxygen in a chest pain patient, or medication if available. Since the initial thread was about BLS pain management, I wanted to post a reminder that the normal BLS regimen was useful, AS WELL AS advanced interventions.

My comment about BLS timidity was a reaction to Rid's post, and admittedly off topic.

How's that?

 

[Jon]

What about Nitrous Oxide? Doesn't that have few side effects, a VERY short half-life, as well as being patient-controlled?

Why doesn't anyone use Nitrous?

 

[BruceD]

What about Nitrous Oxide? Doesn't that have few side effects, a VERY short half-life, as well as being patient-controlled?

Why doesn't anyone use Nitrous?

I do not know why it isn't used, as that isn't my area of expertise, but some things that might present as problems to use on a truck:

1) Nitrous is still relatively potent when exhaled, therefore you would be exposing the care giver and driver to a dissociative drug that decreases mental and physical dexterity.

2) Nitrous is fast acting, short duration, but if a patient uses it or discontinues using it without an adequate supply of oxygen, they run a risk of hypoxia, as the NO2 comes out of the blood fast enough to displace the oxygen in their lungs. I do not know the actual risk of this, only that it can occur.

3) Long term use (I believe, please check this fact) has been teratogenic in some lab tests.

4) (again check this) - I think chronic opiate and benzo use increases tolerance to NO2's medically desirable effects, increasing the risk of #2 above.

5) CNS depressant effects of NO2 can result in hypOtension, which may or may not be desirable.

 

[colafdp]

I do not know why it isn't used, as that isn't my area of expertise, but some things that might present as problems to use on a truck:

1) Nitrous is still relatively potent when exhaled, therefore you would be exposing the care giver and driver to a dissociative drug that decreases mental and physical dexterity.

2) Nitrous is fast acting, short duration, but if a patient uses it or discontinues using it without an adequate supply of oxygen, they run a risk of hypoxia, as the NO2 comes out of the blood fast enough to displace the oxygen in their lungs. I do not know the actual risk of this, only that it can occur.

3) Long term use (I believe, please check this fact) has been teratogenic in some lab tests.

4) (again check this) - I think chronic opiate and benzo use increases tolerance to NO2's medically desirable effects, increasing the risk of #2 above.

5) CNS depressant effects of NO2 can result in hypOtension, which may or may not be desirable.

Actually up here, we still use Nitrous on car. Nitrous is a good drug for minor skeletal injuries and minor burns. But in reply to your two questions..

1) it's either used outside of the unit, or inside the unit with the exhuast fan on in the back. Never had an issue with it being a problem on car to date (knock on wood...haha)

2) even though it's not in our protocols, all of providers that give nitrous always put the SP02 on the patient when we're giving it. We all know that the nitrous might not be mixed to the right concentrations and all of that. Just a better to be safe than sorry type of situation.

5) i can only speak for myself on this, but i try not to give nitrous to somebody that is hypotensive. Just a personal thing, and not everyone may do it. I've never seen anybody get hypotensive from nitrous, but i'm not saying it hasn't happened. It's just usually, people are flying high before they can get enough nitrous into them to really affect their blood pressure.

it was a long day, so if anythin is confusing, i apologize.

 

[Ops Paramedic]

A lot has already been said on this thread, thus hoping this post will still be appropiate!!

I am a firm believer that the EMS is team sport, hence a BLS is only as good as their ALS, whom they look to for leading them, and vice versa, an ALS is as good as those he leads. The ball is in your court to make a cumalitive effort.

Would you allow a Neurosurgeon to perform a caronary artery bypass graft on you??, If the answer is yes, then you most likely need neurosurgery, rather than a CABG. Should the answer be no, then the the origanal question posted is answered for me. I am on board with rid: want to administer a medication, get the piece allowing you to do so.

The EMS is a young and growing profession (Compaired to Medicine), so we will expeirence growing pains throughout. We all hope that the system is failsafe, but i don't think it is. If it was there would be ALS on each ambo and there would be enough ambos to around. But there isn't always, here by us anyway. Our ambos are crewed be an ILS & a BLS, and the ALS roam around between calls where he might be, or is needed, on a Response Car (Non patient carrying capabilities). So there are plenty of times where crews do not always have ALS back-up at their leisure. My advice to them is to adapt themselves to the specific situation they are in, and follow your training. I am not aware of any patient whos has died as a result of PAIN, so to the BLS, use your recources only when needed, otherwise they may be waisted for some else who really need them.

Barring the patient being unable to talk, i offer the patient analgesia, should he fit the criteria. Funny enough, some of them refuse, be it for religous reasons of just a high pain threshold. For for patients who cannot verbally communicate, and have an injury or disease that can induce pain, i administer analgesia to. PS- in 2007 they removed one of our Analgesic agents off protocol: Tramadol HCl (Trade name is Tramal) S5. The reasons is unbeknown to me. Although it has a nasty side effect (Does regurly induce nausea, often coupled with vomiting) it defenitly had a place in pre-hospital setting. Now our only analgesic is Morpine.

 

[BruceD]

Actually up here, we still use Nitrous on car. Nitrous is a good drug for minor skeletal injuries and minor burns. But in reply to your two questions..

1) it's either used outside of the unit, or inside the unit with the exhuast fan on in the back. Never had an issue with it being a problem on car to date (knock on wood...haha)

2) even though it's not in our protocols, all of providers that give nitrous always put the SP02 on the patient when we're giving it. We all know that the nitrous might not be mixed to the right concentrations and all of that. Just a better to be safe than sorry type of situation.

5) i can only speak for myself on this, but i try not to give nitrous to somebody that is hypotensive. Just a personal thing, and not everyone may do it. I've never seen anybody get hypotensive from nitrous, but i'm not saying it hasn't happened. It's just usually, people are flying high before they can get enough nitrous into them to really affect their blood pressure.

it was a long day, so if anythin is confusing, i apologize.

Good to know! thanks for the info

-B