Pain Medication vs Employment

[RocketMedic]

Recently, I have found myself at the center of an ethical debate: our narcotic-use protocol is reliant entirely on physiological signs and symptoms of pain and "paramedic discretion" regarding when pain management is appropriate. I work in a fairly urban system with average patient contact times of <40 minutes. We carry morphine and fentanyl for pain, with fairly conservative dosing schedules. Recently, I have found out that my pain management, although entirely within protocol, may not have been...consistent with the prevailing culture and practices of the organization and its employees as an average. Bluntly, I have the Eye of Sauron on me for managing pain where some others would not have.

In hindsight, some of these people were 'marginal' pain patients- 4/10s, chest pain nonpalliated by NTG, short transport times, etc. All were within protocol and had legitimate complaints and were in evident distress. All received apprpriate doses withpartial or total resolution of pain and no negative outcomes. Still, the Sauron Eye from on high. However, that brokers a host of ethical questions- how much is too much pain, how much is enough to justify pain management via narcotic? More pragmatically, what is the best way to avoid possible 'termination' or negative employment consequences while remaining a good patient advocate? Advice I received from our QI was a complete politican-class nonanswer, other trusted advice was a complete abstinence from their use with the sole goal of dropping my use statistics to "normal". (Said trusted source has been in this position before).

What is a best practice to balance patient comfort vs employment? Should pain even be treated, and to what extent? How right or wrong is it to make decisions based on how my narc use will be tracked in comparison to "never ever" or "hospital is five minutes away"? (Both an ethical and an employment decision). I literally felt bad when I medicated terminal cancer whod been rationing her own pain meds and was suffering quite visibly from excruciating abdominal pain- I really think I might get in trouble for doing theright thing.

Your thoughts?

 

[sir.shocksalot]

I'll avoid going too deep into the "your agency has an culture problem" and "work elsewhere". I'm sorry you're stuck in a situation when it sounds like you are doing right by your patients. I too am "aggressive" (I think it's reasonable, but what do I know?) with pain medication and it's my opinion that patients should be comfortable. If comfortable means a pillow and a smile, so be it. If comfortable means 200mcg of Fentanyl and 2mg of Versed, well that's okay too. I have worked places and encountered people who are very much belonging to the group of "If it doesn't look painful or they aren't tachycardic/hypertensive then they aren't getting meds" having some fanciful notion they are preventing frequent flyers and not feeding narc seekers. I won't get too much into the ethics of that since I think 90% of people on this board agree that people in pain should have their pain relieved.

I think the most reasonable and ethical advice I could give would be to be more selective about who you give narcs to. I'm very against withholding pain medication from people in pain but the reality of your situation is that you might lose your job if you don't. As much as I love taking away my patients pain... I still need food, a roof over my head, gas in my car, it's just not sensible to be unemployed to prove a point. Maybe you need to pick and choose those who really, really need it. Maybe you need to only give pain meds to people with fractures or kidney stones or something along those lines. Give yourself some guidelines of who you'll medicate that are conservative but realistic. Maybe shoot for only giving out half as much narcotics as usual, and start getting really used to saying "I'm sorry you're in pain, we'll get you to the hospital soon". I would advise against completely stopping giving pain medication because I consider that far less ethical than withholding from some people. Playing a numbers game at the expense of someone with a hip fracture is cruel, even for an EMS agency with a culture that would condone such a thing.

I assume your medical director is on board with the whole no pain meds unless you are tachy/hypertensive? If it's more of a QA/QI person thing or general agency culture thing is there anyway you can chat with your medical director about it? Actually I would chat with the medical director regardless. It's 2013 not 1813, we shouldn't be giving people belts to chew on and a prayer. Patients should not be in pain, and pain is an entirely subjective experience. The problem with physiologic criteria is that it's unreliable for a large number of patients. If you have an athlete with a resting heart rate of 50 who is currently at a rate of 80 with symptoms of a kidney stone does that mean he isn't in pain because he's below 100? I don't think so either. I could go on for a few pages about my issues with EMS and pain control but I feel like I would just be viciously flogging a deceased equine creature. Good luck.

 

[RocketMedic]

I'll avoid going too deep into the "your agency has an culture problem" and "work elsewhere". I'm sorry you're stuck in a situation when it sounds like you are doing right by your patients. I too am "aggressive" (I think it's reasonable, but what do I know?) with pain medication and it's my opinion that patients should be comfortable. If comfortable means a pillow and a smile, so be it. If comfortable means 200mcg of Fentanyl and 2mg of Versed, well that's okay too. I have worked places and encountered people who are very much belonging to the group of "If it doesn't look painful or they aren't tachycardic/hypertensive then they aren't getting meds" having some fanciful notion they are preventing frequent flyers and not feeding narc seekers. I won't get too much into the ethics of that since I think 90% of people on this board agree that people in pain should have their pain relieved.

I think the most reasonable and ethical advice I could give would be to be more selective about who you give narcs to. I'm very against withholding pain medication from people in pain but the reality of your situation is that you might lose your job if you don't. As much as I love taking away my patients pain... I still need food, a roof over my head, gas in my car, it's just not sensible to be unemployed to prove a point. Maybe you need to pick and choose those who really, really need it. Maybe you need to only give pain meds to people with fractures or kidney stones or something along those lines. Give yourself some guidelines of who you'll medicate that are conservative but realistic. Maybe shoot for only giving out half as much narcotics as usual, and start getting really used to saying "I'm sorry you're in pain, we'll get you to the hospital soon". I would advise against completely stopping giving pain medication because I consider that far less ethical than withholding from some people. Playing a numbers game at the expense of someone with a hip fracture is cruel, even for an EMS agency with a culture that would condone such a thing.

I assume your medical director is on board with the whole no pain meds unless you are tachy/hypertensive? If it's more of a QA/QI person thing or general agency culture thing is there anyway you can chat with your medical director about it? Actually I would chat with the medical director regardless. It's 2013 not 1813, we shouldn't be giving people belts to chew on and a prayer. Patients should not be in pain, and pain is an entirely subjective experience. The problem with physiologic criteria is that it's unreliable for a large number of patients. If you have an athlete with a resting heart rate of 50 who is currently at a rate of 80 with symptoms of a kidney stone does that mean he isn't in pain because he's below 100? I don't think so either. I could go on for a few pages about my issues with EMS and pain control but I feel like I would just be viciously flogging a deceased equine creature. Good luck.

Im still pretty new here, not sure how politically intelligent it would be to approach the medical director. I think the origination of this is a general organizational culture, stiffened by our OMD people. Im not sure on the docs thoughts, but I suspect they are similar to the agency's.

 

[sir.shocksalot]

Im still pretty new here, not sure how politically intelligent it would be to approach the medical director. I think the origination of this is a general organizational culture, stiffened by our OMD people. Im not sure on the docs thoughts, but I suspect they are similar to the agency's.

Maybe don't approach him in an overt manner. I'm not sure if you see him at the hospital ever (I'm guessing you have a large number of hospitals in your area so you may not ever see him), if you do that would be a good opportunity after bringing in a patient you medicated and asking about his opinions on prehospital pain control? Or at a conference or meeting? Or stalk him at home and wait outside his window and ask him then

Otherwise I think you might be SOL. Do your best to cut back on who you give narcs to and hope that you can eventually wait it out until the paradigm changes. It might be a long haul but cultures do change in EMS agencies, unfortunately it seems to need to start at the top.

 

[Clare]

The source of the pain is not important
The transport time is not important
Physiology is sometimes important (if very low blood pressure/unstable)

Other than that ... nothing else is important other than relief of the patients pain.

I don't believe any of this crap about morphine will stop patients breathing, they will be at the hospital soon so don't worry about it, eh, I can't be bothered, their pain is not real, its all in their head, whatever, I don't buy into any of it. I have seen people who have bad blood pressure etc get very small doses of intravenous pain relief (e.g 1 mg of morphine or 10 mcg of fentanyl) because even tho they are sick relief of their pain is still so very important

If somebody is in pain they get pain relief until they are no longer in pain it's that simple.

When the Paramedics came got me for my tummy they took one look at me and saw I was in significant pain, first thing they did was whip out the IV roll to get a drip in me and said "we're going to give you some pain medicine" and I am the same way with my patients.

The only limiting factor is their physiology (if they are very unwell) or the physical amount of pain relief we carry on us; everything else pales into insignificance!

 

[Veneficus]

Let me just take the gloves off.

You agency sucks, period.

It is the typical "high performance" system, which means they run a lot of calls, drive a lot of people to the hospital, and don't do $h!T for them.

At least the FTO/QI/QA are good old boys who got their position on seniority not ability. It is so common in "high performance" systems that I cannot name even one system who claimed to be such that wasn't like that.

Most reputable agencies use the code word "progressive." As in progress from the middle ages.

I have been giving this matter some thought, even if you talk to your medical director, something I highly suggest, your supervising people will likely feel butt hurt and find other reasons to "get rid of you."

In the end, your values do not match with your organization. Which means you are going to be looking for another job soon anyway, simply because even if you toe the line, you will be so miserable that you will have to get out or you will burn out.

Really the only question is how much harm you do to yourself and those close to you before you realize it.

Don't go out with a bang, just fade away. Smile, nod, thank your "superiors" for their insights, and keep your pay cheque. When not at work, fnd better work. It's out there.

Don't try to change ambulance drivers into paramedics. It is not worth the headache.

If they actually were worried about too much narcs, like many progressive agencies, they would have something other than narcs to give.

 

[NYMedic828]

Sounds a lot like trying to give pain meds in NYC.

In the last 2 years I gave morphine a total of 4 times due to either:

-Partner is uncomfortable giving pain meds usually due to incompetence/lack of education
-Medical director too strict based on not trusting providers they govern.
-Protocols too strict.

If I told my partner I wanted to give pain meds they would usually look at me like I had two heads and say it wasn't needed or we are 5 minutes from the ER.

I have never given fentanyl because everyone I worked with thought it was just too strong... Not like the dose is equivalent or anything.

 

[Anjel]

If someone is in pain. And we can do something about it, why would we. If your boss broke his leg and his pain was a 5/10. I'm sure he would want pain meds.

 

[Christopher]

Recently, I have found myself at the center of an ethical debate: our narcotic-use protocol is reliant entirely on physiological signs and symptoms of pain and "paramedic discretion" regarding when pain management is appropriate. I work in a fairly urban system with average patient contact times of <40 minutes. We carry morphine and fentanyl for pain, with fairly conservative dosing schedules. Recently, I have found out that my pain management, although entirely within protocol, may not have been...consistent with the prevailing culture and practices of the organization and its employees as an average. Bluntly, I have the Eye of Sauron on me for managing pain where some others would not have.

In hindsight, some of these people were 'marginal' pain patients- 4/10s, chest pain nonpalliated by NTG, short transport times, etc. All were within protocol and had legitimate complaints and were in evident distress. All received apprpriate doses withpartial or total resolution of pain and no negative outcomes. Still, the Sauron Eye from on high. However, that brokers a host of ethical questions- how much is too much pain, how much is enough to justify pain management via narcotic? More pragmatically, what is the best way to avoid possible 'termination' or negative employment consequences while remaining a good patient advocate? Advice I received from our QI was a complete politican-class nonanswer, other trusted advice was a complete abstinence from their use with the sole goal of dropping my use statistics to "normal". (Said trusted source has been in this position before).

What is a best practice to balance patient comfort vs employment? Should pain even be treated, and to what extent? How right or wrong is it to make decisions based on how my narc use will be tracked in comparison to "never ever" or "hospital is five minutes away"? (Both an ethical and an employment decision). I literally felt bad when I medicated terminal cancer whod been rationing her own pain meds and was suffering quite visibly from excruciating abdominal pain- I really think I might get in trouble for doing theright thing.

Your thoughts?

Aggressive pain management is just as cool as placing an endotracheal tube without contributing to hypotension or hypoxia...I probably overtreat pain by conventional EMS standards, but working at an educational service we often spend extra time with a student/preceptee securing a line and discussing Rx plans and executing them (nb: the plans, not patients or students/preceptees).

That being said, we still have a big problem with 2 mg of morphine being the total dose given. How odd that almost 1 in 4 patients receiving morphine happen to be 50 lbs...

Simple answer? Call medical control on cases where you think it'll be looked down upon and get orders. Or, if you're treating within protocol simply reference the protocol whenever you document administration.

"Pain rated 6 of 10, patient denies allergies to morphine, per protocol for adult pain administered 4 mg morphine slow IVP."

 

[RocketMedic]

Aggressive pain management is just as cool as placing an endotracheal tube without contributing to hypotension or hypoxia...I probably overtreat pain by conventional EMS standards, but working at an educational service we often spend extra time with a student/preceptee securing a line and discussing Rx plans and executing them (nb: the plans, not patients or students/preceptees).

That being said, we still have a big problem with 2 mg of morphine being the total dose given. How odd that almost 1 in 4 patients receiving morphine happen to be 50 lbs...

Simple answer? Call medical control on cases where you think it'll be looked down upon and get orders. Or, if you're treating within protocol simply reference the protocol whenever you document administration.

"Pain rated 6 of 10, patient denies allergies to morphine, per protocol for adult pain administered 4 mg morphine slow IVP."

Thats what I've been doing. I think Veneficus nailed it in one.

 

[Carlos Danger]

our narcotic-use protocol is reliant entirely on physiological signs and symptoms of pain and "paramedic discretion" regarding when pain management is appropriate.

Your pain management protocol relies on everything except the patient's rating of their own pain?

I have been giving this matter some thought, even if you talk to your medical director, something I highly suggest, your supervising people will likely feel butt hurt and find other reasons to "get rid of you."


In the end, your values do not match with your organization.

Don't go out with a bang, just fade away. Smile, nod, thank your "superiors" for their insights, and keep your pay cheque. When not at work, fnd better work. It's out there.

This.

You need to find a new job from the sounds of it.

But you need to be careful about how you get out. "He's the guy who gives too much narcotic" is not a label you want following you; it has several negative connotations.

Simple answer? Call medical control on cases where you think it'll be looked down upon and get orders. Or, if you're treating within protocol simply reference the protocol whenever you document administration.

I don't think this will help your situation, assuming what you've been doing really is already within protocol. If your QI folks think you use too much narc, their mind isn't going to be changed just because you document better.

I would start contacting MC regularly for narc orders, and be careful about having your waste documented by reliable people. Just to CYA until you find new employment.


Here's some food for thought:

Are you sure there isn't something to the criticism you've been getting?

Are you sure you perhaps haven't been a little loose with the narcs?

Are you sure there isn't something about your documentation that doesn't justify the criticism?

Here's the thing: There are people who "get off" on giving generous doses of narcotics unnecessarily. There are also people who chart large doses and give small doses so that they can divert the balance. I'm not at all accusing you of either; what I'm asking is, is there any chance that something you are doing may be giving someone the impression that something is amiss?

I'm not trying to be critical, just making sure you are considering everything.

Because you'll just have the same problem at your next place if you aren't confident that there's nothing about your documentation that makes it look like something isn't right.

 

[Milla3P]

Is this possibly a supply/ ordering issue? National shortages and all.

Are the QA/QI guys friends with the bean counters? Or logistics?
"We're almost out of narcs" or "I don't want to order narcs so often. Tell this guy to ease up"

Either way, start looking.

 

[RocketMedic]

Your pain management protocol relies on everything except the patient's rating of their own pain?

Yep. All we get is "paramedic discretion" and a floor of 100 systolic bp or OLMC consult for pediatric patients.


This.

You need to find a new job from the sounds of it.

But you need to be careful about how you get out. "He's the guy who gives too much narcotic" is not a label you want following you; it has several negative connotations.



I don't think this will help your situation, assuming what you've been doing really is already within protocol. If your QI folks think you use too much narc, their mind isn't going to be changed just because you document better.

I would start contacting MC regularly for narc orders, and be careful about having your waste documented by reliable people. Just to CYA until you find new employment.


Here's some food for thought:

Are you sure there isn't something to the criticism you've been getting?

Are you sure you perhaps haven't been a little loose with the narcs?

Are you sure there isn't something about your documentation that doesn't justify the criticism?

Here's the thing: There are people who "get off" on giving generous doses of narcotics unnecessarily. There are also people who chart large doses and give small doses so that they can divert the balance. I'm not at all accusing you of either; what I'm asking is, is there any chance that something you are doing may be giving someone the impression that something is amiss?

I'm not trying to be critical, just making sure you are considering everything.

Because you'll just have the same problem at your next place if you aren't confident that there's nothing about your documentation that makes it look like something isn't right.

All of the documentation is correct, I even give rationale for what I do. All witnessed, no issues with erroneous or incomplete documentation. No thoughts at all of diversion.

Hoping not to open the box tonight.

 

[Akulahawk]

I think much of the problem is that your service has a culture of making patients "suck it up" and just simply deal with the pain. The fact that you are providing excellent care and good pain control means that you are giving more narcotics then they statistically use, so your use probably stuck out like a sore thumb.

 

[RocketMedic]

Is this possibly a supply/ ordering issue? National shortages and all.

Are the QA/QI guys friends with the bean counters? Or logistics?
"We're almost out of narcs" or "I don't want to order narcs so often. Tell this guy to ease up"

Either way, start looking.

That may play a part, but I get the impression that its a mentality.

 

[Christopher]

Here's the thing: There are people who "get off" on giving generous doses of narcotics unnecessarily. There are also people who chart large doses and give small doses so that they can divert the balance. I'm not at all accusing you of either; what I'm asking is, is there any chance that something you are doing may be giving someone the impression that something is amiss?

You do realize that this is not a known problem in medicine.

The known problem is NOT giving enough narcotics.

 

[RocketMedic]

You do realize that this is not a known problem in medicine.

The known problem is NOT giving enough narcotics.

I fail to see how aggressively intubating people, using electrical therapy, or pushing meds is any different from simply managing pain appropriately. We, as a profession, are all about RSI, trauma care, and all sorts of Ricky Rescue BS...yet we draw a line between pain management meds and something like glucagon or adenosine.

 

[Carlos Danger]

You do realize that this is not a known problem in medicine.

The known problem is NOT giving enough narcotics.

I think you are missing the point.

 

[Akulahawk]

You do realize that this is not a known problem in medicine.

The known problem is NOT giving enough narcotics.

The first part, I've never heard about either. The second problem is known as diversion. You chart that it's given and you either don't, or you give a smaller dose, and keep the rest for yourself. That is a known problem in medicine.

The second problem you're likely facing is that the company you work for really doesn't like to use such a big hammer (narcotics) for controlling something that just really can't be reliably measured. While I'm sure your administration of the drugs is completely within protocol, their mentality kind of persuades their medics to NOT give pain relief, and therefore when someone actually does it by the book, the utilization of narcotics goes way up relative to the rest of the group.

The reason I say that narcotics is a big hammer for pain control is that while you could use an ice pack for low level pain, (say 3/10 pain) we just don't have anything that's widely available in the US for pain control in the 3/10 - 7/10 range. I'd call that "moderate" pain. Above that, use the hammer to drive the pain level to 3/10 or less.

Unfortunately, in the US, pain control is still something that's very poorly done. To make matters worse, I've heard (many times) of patients just "sucking up" the pain and minimizing it because they believe that they'll become addicted to morphine used to control the pain.

That may be a part of where the mentality your service has, comes from. And it completely sucks that you're caught in it all because you're actually doing patient care the way it should be done.

 

[Veneficus]

To make matters worse, I've heard (many times) of patients just "sucking up" the pain and minimizing it because they believe that they'll become addicted to morphine used to control the pain.

This happens everywhere, not just the US.

Some cultures do not accept narcotic use.

Some cultures do not readily express pain.

I just explain to them it is likely a 1 or 2 time thing or for their surgery.

There are all kinds of ways to control pain, not everything requires high dose narcs or even narcs at all. But for some reason EMS desn't usually use anything other than opioids. A handful of services have toradol, but you are still dealing with an IV med. PO naproxin solves a lot of problems. It doesn't even have a fast enough onset to keep people from going to the ER.