Pain Medication vs Employment

[lightsandsirens5]

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.

I would love to be able to give Naproxin. I am able to give Totadol as well, which I give like it's going out of style.

But Vene, in a culture like ours, that seems to readily express pain, why do you think there is such an aversion to pain control?

 

[Akulahawk]

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.

Vene: believe me, I would absolutely be overjoyed if we could use PO naproxen, ibuprofen or something similar to bridge that gap between mild pain and the severe-opiate-needed pain. Heck, even if it could be given IM or IV for faster onset that would be great because then if pain control was the only thing needed, it could be easily provided, stay ahead of it, allowing the patient the pain relief desired while allowing the EMS system to be available faster and still be an option for later transport/further pain control if needed.

Did I mention that I really like naproxen? Just 2 little pills and I'm going to get at least 12 hours of pretty decent pain relief... if I ever needed anything stronger, well, then I'm sure I'd really need something a lot stronger...

Oh, and I also try to explain that when used appropriately, narcotics normally don't result in addiction...

 

[Medic Tim]

Vene: believe me, I would absolutely be overjoyed if we could use PO naproxen, ibuprofen or something similar to bridge that gap between mild pain and the severe-opiate-needed pain. Heck, even if it could be given IM or IV for faster onset that would be great because then if pain control was the only thing needed, it could be easily provided, stay ahead of it, allowing the patient the pain relief desired while allowing the EMS system to be available faster and still be an option for later transport/further pain control if needed.

Did I mention that I really like naproxen? Just 2 little pills and I'm going to get at least 12 hours of pretty decent pain relief... if I ever needed anything stronger, well, then I'm sure I'd really need something a lot stronger...

Oh, and I also try to explain that when used appropriately, narcotics normally don't result in addiction...

At my industrial job I have morphine, fentanyl, ketamin, toradol , and a handful of different OTC pain meds. The clinic has an even better selection.

It is nice to have non narcotic options.

 

[katgrl2003]

We just recently (within the last year) started giving PO Tylenol and Toradol. Most medics aren't using the Tylenol, but Toradol is great. Unfortunately, because of all the contraindications with Toradol, Fentanyl is still getting quite a bit of use.

 

[DesertMedic66]

In the 2 years I have been on an ambulance I have only seen morphine given 5 times. All 3 times it was needed but there were many other times where the medic should have given the patient pain control.

I wish my service/county had other options for pain control aside from morphine (fent is currently being discussed).

Our agency is not against us giving pain meds when it is called for. Heck at the end of the year we give out a company award for the "candy man" or "candy woman". It's an award (I use award lightly. It's more of a joke) that is given out to the medic who used the most amount of morphine during the year.

Things might start changing when the drug shortage starts to get to us. Right now the only drug we have a shortage of is D50 preloads.

 

[katgrl2003]

Things might start changing when the drug shortage starts to get to us. Right now the only drug we have a shortage of is D50 preloads.

You lucky bugger. We have no D25, bicarb, low on atropine, low on epi (both forms) and all sorts of others.

 

[Clare]

We just recently (within the last year) started giving PO Tylenol and Toradol. Most medics aren't using the Tylenol, but Toradol is great. Unfortunately, because of all the contraindications with Toradol, Fentanyl is still getting quite a bit of use.

How very interesting, what are you giving ketorolac for?

We have been dishing out paracetamol for ages; its great stuff if used wisely, so here is what I have learnt that I did not know and hope it helps

1) You must give it in quite a high dose for it to be truly effective (higher than what is on the packet of the tablets sold at the supermarket or chemist) we use 20 mg/kg and I round up to the nearest 500 mg (i.e. 60 kg person should get 1,200 mg but they get 1,500 mg). This does not risk paracetamol poisoning (which many people are afraid of, even health care professionals I have noticed!) provided you give it a a single dose and instruct the patient not to have any more for four hours.

2) A lot of paracetamol seems to be given to patients with mild to moderate fever and signs of an infection; a fever (heat) is one of the universal signs of inflammation (i.e. immune response) and therefore is a sign that the body is working to fight whatever infection is present so likely confers benefit and shouldn't really be given unless the patient is significantly uncomfortable or has a temp of > 40 degrees.

Are you using paracetamol tablets or syrup? We use both but I hate the tablets, we use cheap generic ones and they taste absolutely terrible, bitter, horrid and nasty, the syrup tastes quite nice so we draw it up into a 20 ml syringe and give it to patient for swallow and its great.

You lucky bugger. We have no D25, bicarb, low on atropine, low on epi (both forms) and all sorts of others.

There is more than one form of adrenaline? I know we carry two dilutions of midazolam but never heard of two forms of adrenaline!

 

[NomadicMedic]

I worked at a service that had plenty of pain management options, and you were expected to use them, no questions asked. Toradol for kidney stones, fent and/or morphine, along with phenergan. Pain management could also be paired with a benzo. It was nice to be able to do what was right for the patient.

Here, not so much. They certainly don't frown on pain management, but it's not as free wheeling as my last job.

And Clare, most of us carry both Epi 1:100 and preloads of Epi 1:10,000.

 

[Clare]

This is very interesting reading; a research thesis on pain relief within the Auckland District presented by one of the Intensive Care Paramedics although it should be noted that it is a few years old and uses the old qualification structure which no longer exists

http://aut.researchgateway.ac.nz/bitstream/handle/10292/1401/WernerS.pdf?sequence=3

And Clare, most of us carry both Epi 1:100 and preloads of Epi 1:10,000.

1) Points for spelling it right
2) I think we had this discussion elsewhere, the prefilled yellow thing
3) Still seems very unusual, but ...

 

[Christopher]

I worked at a service that had plenty of pain management options, and you were expected to use them, no questions asked. Toradol for kidney stones, fent and/or morphine, along with phenergan. Pain management could also be paired with a benzo. It was nice to be able to do what was right for the patient.

Here, not so much. They certainly don't frown on pain management, but it's not as free wheeling as my last job.

Starting 1 April I'll have dilaudid, fentanyl, and morphine at both of the ALS services I work at, for narcotic analgesia options (with tylenol, ibuprofen, and toradol as well). Couldn't imagine not having the options or freedom to treat pain.

 

[usalsfyre]

Specifically wrote pain management options for everything from PO acetaminophen to sub-anesthetic ketamine (which we can't seem to get right now) into our protocols.

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.
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?

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?

Yet again this rumor is perpetuated. My last two jobs prior to coming off the truck I was one of, or the, person who administered the most narcs on several occasions. You know what I heard about it? Nada...zippity...zilch. I currently monitor all of the narc usage for my service. You want to guess what I say to people who treat pain aggressively? Three guesses and the first two don't count...

You wouldn't get suspicious of the guy who used the most saline would you?

It's yet another culture issue in EMS that needs to go away.

 

[Veneficus]

But Vene, in a culture like ours, that seems to readily express pain, why do you think there is such an aversion to pain control?

I think it is a complicated issue.

First, med students, nursing students, etc all hear horror stories about how dangerous narcs are. You would think anyone you gave 2 mg of morphine to was going to stop breathing and instantly go into unrecoverable cardiac arrest just like some colleagues uncle's brother's niece's youngest sibling once saw.

I was talking about opioid administration with a doctor I have the highest respect for, his anecdote was that once in his 20+ year career he saw a patient with a bad reaction and ever since has urged caution in usage. (one of the reasons I am not too keen on "number needed to treat" and "number needed to harm" statistics. There must be hundreds of thousands of doses of opioid given out every day around the world, coupled with illegal use, there could be an estimated handful of negative reactions.

The idea that if it harms one person, we should stop doing it. Good thing surgery doesn't take that approach.

The US is actually not really multicultural, it is one culture that demands conformity, but permits some deviation.

If you look at most senior doctors today though, they are usually men, white men, who grew up during a time when it was "manly" to accept pain. Consequently, their idea of what "really should hurt" and therefore requires pain control is a little skewed.

Which leads to the issue of assigning pain based on injury. What "should hurt" and "how much."Which of course is not only highly subjective, but accounts only for nociceptive pain. However, pain is not just nociceptive, and only the most progressive will treat the neurological pain.

Some places, like US EDs are actually stressed to meet "safety" guidlines and not mix opioids with benzos except as conscious sedation. (which of course is ridiculous, but there is always that story of the one time...) Many of my US EM friends actually tell me they wish they had the freedom to mix and match more liberally, but their agency prohibits it on "safety" grounds.

Additionally, there is the "ambulances are for emergencies" attitude, even among physicians. they equate not having an "emergency" with not deserving of help, especially pain management. It is well known that more pain management is needed when moving and transporting patients then when they lay in hospital beds.

Some doctors are still under the impression that reducing pain will interfere with an abdominal exam. Which has been not only debunked in studies, but shown that managing the pain helps in them. Modern imaging, especially ultrasound and CT have all but eliminated the physical exam of the abd in the US. There are actually studies showing how inaccurate the physical exams there are. (probably because they have become reliant on imaging, but that is another topic)

Because of the simplified nature of EMS education, treatments are taught as either "right or worng."

Consequently you run into what rocket did, if you are not doing what everyone else is, if they are right, you must be wrong.

"you're going to kill the patient!" or "you killed the patient" is part of EMS training. Along with the unreasonable expectation a treatment will never harm or that providers will never make a mistake.

I once heard in medical school "every doctor owns a little pice of the cemetary." Yet we do not fire or remove the license of every doctor who makes a mistake or has a patient with a negative outcome.

Some have the crazy idea that no mistake or poor outcome will be made if you do nothing. But that is not true.

I think there is also a problem with EMS education being focus on the extreme. It makes sense that if the patient is "not about to die" that rendering treatment is considered inappropriate to providers. Afterall, they are "not sick.'

Like all things, in medicine or out, there is never a simple answer. Life is a dynamic, multifactorial system. I think as generations change as well as medicine and healthcare now seeing more women than men in its ranks, as the upper level people change, pain control will become more of an accepted and expected treatment.

 

[Carlos Danger]

The known problem is NOT giving enough narcotics.

More accurately, the problem is "not effectively managing pain". Effective pain management does not necessarily = opioids.

Yet again this rumor is perpetuated. My last two jobs prior to coming off the truck I was one of, or the, person who administered the most narcs on several occasions. You know what I heard about it? Nada...zippity...zilch.

Good for you. Do you think every else's experience is identical to yours?

You wouldn't get suspicious of the guy who used the most saline would you?

First of all, that's a very poor analogy because there are obviously big differences in how we account for schedule II drugs vs. non-controlled drugs.

But secondly, I actually would investigate why someone were consistently using significantly more NS than others. NS is not a benign drug, and it is not free to the company.

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.

"The first part" (some paramedics intentionally giving more narcotic than they need to) definitely happens, and I can assure anyone that and diversions are considerations in the mind of someone looking at the charts of a paramedic who consistently gives doses of opioids that are well above the mean. I am not at all accusing the OP of that; was just suggesting that perhaps the management could view that as a possibility.

Opioids are indeed a "big hammer" for mild pain, which is a big part of the reason why so many managers and medical directors don't like to see them used unless "absolutely necessary".

Another reason is regulatory issues. As street paramedics, we don't see the bureaucracy surrounding the purchase, transfer, storage, and administration of opioids that occurs at the managerial level. It is not a small thing, and federal audits and investigations are becoming more common and more invasive as prescription opioid abuse grows as a problem. Right or wrong, I wouldn't be surprised to see more managers and medical directors start to more closely scrutinize the administration of opioids because of this.

 

[46Young]

Things might start changing when the drug shortage starts to get to us. Right now the only drug we have a shortage of is D50 preloads.

We've been substituting 25G of D50% with 250ml bags of D10%. The pharmacy has plenty of those available.

 

[46Young]

If anything, where I work, if we withhold pain management, we can get jammed up. We have more of a problem of lazy providers looking for a reason to defer pain management, because they don't want to spend the time replacing meds at the pharmacy. It isn't a widespread problem, but it does occur.

The thing I like most about being a medic is the treatments that have a rapid positive response with the pt. Pain management, D50 for an altered diabetic, epi for the anaphylaxis, benzos for a Sz are where it's at.

 

[RocketMedic]

Halothane, although we don't track saline use here, I guarantee that I am in the top 25% of NS users in my agency for NS hangs for IVs (and not everyone gets a line, Im far below average for Pointless IVs). If they are getting meds or an IV, I hang a bag TKO, primarily as a flush, and to allow hands-free access from my restrained seat with minimal fuss. This lets me secure catheters well (especially in hands and joints) and sidestep my agencys lack of a long hep lock. Most of our medics dont do this. When asked why, I pointed out that I rarely had a reason to unbelt when rolling, as I could push meds, reassess and chart from my captains seat.

 

[RocketMedic]

If anything, where I work, if we withhold pain management, we can get jammed up. We have more of a problem of lazy providers looking for a reason to defer pain management, because they don't want to spend the time replacing meds at the pharmacy. It isn't a widespread problem, but it does occur.

The thing I like most about being a medic is the treatments that have a rapid positive response with the pt. Pain management, D50 for an altered diabetic, epi for the anaphylaxis, benzos for a Sz are where it's at.

I love diabetic wakeups. Had one the other day who went out on her porch and spent a good 25 minutes unconscious outside before her husband found her. BGL 24 to 80 witb 1mg glucagon, no IV access due to many, many dialysis fistulae and scars over old veins, core temp 96.5 degrees per hospital. Fire looked at me like a champion when I showed up, whipped out the Glucagon and pulled her into the toasty rig instead of literally working her where she was. What scares me is that some of our medics would have left her on the floor for minutes while hunting for a vein.

 

[RocketMedic]

We've been substituting 25G of D50% with 250ml bags of D10%. The pharmacy has plenty of those available.

I like this. Way safer for IV infusion.

 

[RocketMedic]

More accurately, the problem is "not effectively managing pain". Effective pain management does not necessarily = opioids.




Good for you. Do you think every else's experience is identical to yours?



First of all, that's a very poor analogy because there are obviously big differences in how we account for schedule II drugs vs. non-controlled drugs.

But secondly, I actually would investigate why someone were consistently using significantly more NS than others. NS is not a benign drug, and it is not free to the company.




"The first part" (some paramedics intentionally giving more narcotic than they need to) definitely happens, and I can assure anyone that and diversions are considerations in the mind of someone looking at the charts of a paramedic who consistently gives doses of opioids that are well above the mean. I am not at all accusing the OP of that; was just suggesting that perhaps the management could view that as a possibility.

Opioids are indeed a "big hammer" for mild pain, which is a big part of the reason why so many managers and medical directors don't like to see them used unless "absolutely necessary".

Another reason is regulatory issues. As street paramedics, we don't see the bureaucracy surrounding the purchase, transfer, storage, and administration of opioids that occurs at the managerial level. It is not a small thing, and federal audits and investigations are becoming more common and more invasive as prescription opioid abuse grows as a problem. Right or wrong, I wouldn't be surprised to see more managers and medical directors start to more closely scrutinize the administration of opioids because of this.

True mild pain, agree. I dont treat that. Moderate pain though...absent any authorized non-opiates, what are you to do? For that matter, what of severe pain?

 

[Carlos Danger]

True mild pain, agree. I dont treat that. Moderate pain though...absent any authorized non-opiates, what are you to do? For that matter, what of severe pain?

Well, in the prehospital realm, there probably isn't much you can do, unfortunately. Obviously you are at the mercy of your protocols and limited by the drugs that you carry.

Ketorolac is a really good alternative to opioids in many situations. I'm really not sure why it hasn't caught on more in EMS, especially in systems that are afraid of using opioids. There are probably more considerations to it's use than morphine or fentanyl, but it is appropriate in most patients and very effective for most types of acute pain.

Acetaminophen, naproxen and ibuprofen are good for mild-moderate pain but the obvious drawback to their use in EMS is they won't have even started to take effect by the time you get to the hospital.