Pain Medication vs Employment

[Veneficus]

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.

Is that even a problem?

 

[Carlos Danger]

Is that even a problem?

It is if your goal is to provide comfort during transport.

 

[Veneficus]

It is if your goal is to provide comfort during transport.

Good point.

 

[Akulahawk]

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.

Especially when given PO.

Is that even a problem?

It is if your goal is to provide comfort during transport.

Yes, what he said... Ibuprofen and acetaminophen take about 15-30 minutes before onset if they're given IV. If your goal is transport, in cities like Sacramento (and many others) you can be at the hospital before onset occurs. You want something that has a relatively fast onset, and at least here, the only stuff that we're allowed to give is morphine and perhaps fentanyl. Both of those work well for pain but when dealing with mild or moderate pain, they're one huge hammer. There was a post earlier where one medic had a decent selection of pain medication... if only we had those options here!

Anyway, my point is that I just wish we had more options for pain control in the prehospital arena than we do.

 

[Clare]

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.

I am not sure how this is a problem?

Panadol is good for giving to people and leaving them at home if their only complaint is mild to moderate pain (or fever > 40 degrees) that is significantly relieved with panadol.

 

[usalsfyre]

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

No, n=1. However, do you think everyone gets looked at suspiciously for using schedule IIs appropriately?

"The first part" (some paramedics intentionally giving more narcotic than they need to) definitely happens,

Outside of facility complaints, how in Hades do you determine this was the case without being at bedside? Unless the administration was outside protocol, what's to punish?

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.

Really? Because they treat their patients I'm supposed to think they're diverting? (Perhaps I'm simply used to how badly patients are usually UNDERdosed and am estatic to see appropriate dosing)

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.

Big fricking deal. That's why we make the "big bucks". If managers are getting upset over doing their job they need to find a different profession.

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.

If they've been doing their job (from the field medic on up) audits, while scary, are not the nightmare where you go to jail.

 

[Carlos Danger]

No, n=1. However, do you think everyone gets looked at suspiciously for using schedule IIs appropriately?

Everyone? Of course not.

We are talking specifically about people whose managers or medical directors are suspicious of those who give a lot of narcs, are we not?

In which case, by definition, then yes, "everyone" could potentially be looked at suspiciously.

Outside of facility complaints, how in Hades do you determine this was the case without being at bedside? Unless the administration was outside protocol, what's to punish?

I do not know. Maybe you should find some managers who think that way.

Try the OP's boss?

Really? Because they treat their patients I'm supposed to think they're diverting?

Is that even remotely what I wrote?

Big fricking deal. That's why we make the "big bucks". If managers are getting upset over doing their job they need to find a different profession.


If they've been doing their job (from the field medic on up) audits, while scary, are not the nightmare where you go to jail.

Not sure why you are so angry.

I was simply pointing out some potential motivations for the OP's managers being such pricks about him treating patients.

 

[usalsfyre]

Everyone? Of course not.

We are talking specifically about people whose managers or medical directors are suspicious of those who give a lot of narcs, are we not?

In which case, by definition, then yes, "everyone" could potentially be looked at suspiciously.



I do not know. Maybe you should find some managers who think that way.

Try the OP's boss?



Is that even remotely what I wrote?



Not sure why you are so angry.

I was simply pointing out some potential motivations for the OP's managers being such pricks about him treating patients.

Not angry, just frustrated with the traction this stuff gets. I hear it I my service and I'm the manager that would be dealing with it. Repeating this stuff unfortunately indoctrinates the next generation.

 

[Carlos Danger]

Not angry, just frustrated with the traction this stuff gets. I hear it I my service and I'm the manager that would be dealing with it. Repeating this stuff unfortunately indoctrinates the next generation.

Repeating what stuff "indoctrinates" the next generation?

I don't think I even know what we are discussing.

 

[RocketMedic]

Two days without any narc use...trending slowly towards mediocrity and continued employment.

 

[Handsome Robb]

Two days without any narc use...trending slowly towards mediocrity and continued employment.

I'm not sure not using them is the answer, I think dosing is what they're really worried about.

Like I said in the PM I sent ya, the pain scale is subjective and, in my opinion, not the greatest way to determine which patient gets narcotics and which patient doesn't. If it looks like it would hurt me, they appear uncomfortable and/or have physiological signs that support the fact that they're in pain I will dose them until they appear comfortable. If we can get them pain free awesome but as long as they're comfortable who cares what number they throw at you when you ask them to rate their pain.

 

[RocketMedic]

I'm not sure not using them is the answer, I think dosing is what they're really worried about.

Like I said in the PM I sent ya, the pain scale is subjective and, in my opinion, not the greatest way to determine which patient gets narcotics and which patient doesn't. If it looks like it would hurt me, they appear uncomfortable and/or have physiological signs that support the fact that they're in pain I will dose them until they appear comfortable. If we can get them pain free awesome but as long as they're comfortable who cares what number they throw at you when you ask them to rate their pain.

No, its use at all here. "Did they really need it" is a theme.

 

[46Young]

The moment you receive a solid job offer from a more preferable employer, question the QA/QI Nazi:

If the patient were your mother/father/child (as the case may be), would you prefer that they be made comfortable during transport, or would you prefer that your lover one be made to suffer in pain until they're delivered to the hospital, spend time getting triaged, wait for a doctor, get evaluated by the doctor who eventually orders pain meds, which your loved one needs to wait for the pharmacy to deliver, the RN to draw up, and administer? Tell them that you treat every patient as if they were family; would they prefer that you treat them differently?

Further relate to QA/QI that you don't get your "kicks" from giving narcotics, that it's actually a PITA to give them, to spend extra time on documentation, wasting, replenishing the supply from pharmacy, etc. Ask if they would like a blood test to show that you're not getting high from your own supply (a violation of the ten crack commandments, BTW haha)?

Point out departments like mine, who are fairly liberal with the admin of standing order opiates and benzos for various conditions (albeit at somewhat conservative doses), without getting our balls broken.

Since you would be leaving the organization for good at this point, perhaps you could tell them that 1989 is calling, and wants its medical education back. If they ask you where you're going, tell them nunya (nunya business).

 

[46Young]

Two days without any narc use...trending slowly towards mediocrity and continued employment.

If continued employment with this myopic system is your goal, I suppose just withhold narcs unless the pt is very visibly upset due to discomfort. If it's some moderate Cx pain, a rolled ankle, or a dislocated shoulder/hip that can be made somewhat tolerable through splinting and padding, then perhaps just defer pain management to appease the Eye of Sauron.

 

[RocketMedic]

If continued employment with this myopic system is your goal, I suppose just withhold narcs unless the pt is very visibly upset due to discomfort. If it's some moderate Cx pain, a rolled ankle, or a dislocated shoulder/hip that can be made somewhat tolerable through splinting and padding, then perhaps just defer pain management to appease the Eye of Sauron.

PM sent.

 

[WuLabsWuTecH]

the call medical control idea is a very, very good one IMO.

In our protocol, there is actually NO pain management whatsoever for peds. NONE. ZERO. ZILCH!

It was intentionally left this way because our MD wants us to call medical control for each and every peds patient that needs it. Do I agree with it? No, but guess what we're never going to get dinged for? If you contact medical control, then your QA/QI won't be able to ding you for giving meds because it was ordered.

 

[RocketMedic]

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.

Quoted and reposted for truth, he was right.

 

[shfd739]

Quoted and reposted for truth, he was right.

Yes he was.

Hopefully by the end of this year ill be making the same post you just did.

 

[mcdonl]

I will give my perspective as an EMT-I (And medic student).... (Fire/EMS Municiple based, perdiem/volly)

So, clearly I cannot give pain control with narcotics. And, over the past 6 or 7 years I have only needed to get ALS onboard for pain control a handful of times. I find that once the patient is comfortable, the IV is started and all other interventions are in place the 25-30 minutes left in the transport time the patients are typically satisfied that they are comfortable in the ambulance, and on their way to the hospital. Those that are not... well... they are the handful that I called ALS for. Each time, pain control was given.

As a medic student, I am very interested in this subject along with 9,000,000 others....

We had a medic working with us recently and he quickly got a reputation of giving too much pain meds. Everytime was within protocol but because we have fallen into the trap of holding everyone in contempt because of a bad prescription pain medication abuse problem in Southern Maine. He was let go, for "other" reasons but I suspect that this was a contributing factor.

 

[Medic Tim]

I will give my perspective as an EMT-I (And medic student).... (Fire/EMS Municiple based, perdiem/volly)

So, clearly I cannot give pain control with narcotics. And, over the past 6 or 7 years I have only needed to get ALS onboard for pain control a handful of times. I find that once the patient is comfortable, the IV is started and all other interventions are in place the 25-30 minutes left in the transport time the patients are typically satisfied that they are comfortable in the ambulance, and on their way to the hospital. Those that are not... well... they are the handful that I called ALS for. Each time, pain control was given.

As a medic student, I am very interested in this subject along with 9,000,000 others....

We had a medic working with us recently and he quickly got a reputation of giving too much pain meds. Everytime was within protocol but because we have fallen into the trap of holding everyone in contempt because of a bad prescription pain medication abuse problem in Southern Maine. He was let go, for "other" reasons but I suspect that this was a contributing factor.

Maine has a pretty restrictive pain management protocol. Unless it is an isolated injury/fx you need to call olmc. Maybe he was let go for giving it without calling. You also need to call olmc for peds dosing, abnormal vital signs, coincident drug use, and etoh.

But like you said there may have been and probably were other reasons for him to get the boot.