Physicians' Impression of Pre-Hospital Pain Management

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redcrossemt

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Patient Summary: 26 y/o female with worsening left flank pain over the past 3 days. It has been a 2-3 out of 10, just kind of achy; but this morning is a "20" out of 10, woke patient out of her sleep, and she couldn't get back to sleep because of the pain. Patient was tachycardic, tachypneic, wincing, and generally appeared to be in distress. Interventions included 1.5 mcg/kg of fentanyl IV. Our transport time was about 8 minutes.

After patient care had been transferred and report given to nursing staff, the ER physician took me aside and asked me why I had given fentanyl to this particular patient. I reiterated the story above, emphasizing that the patient said she was in severe pain, and appeared to me to be in distress. I also reiterated our pain management protocol, and that the pre-hospital standard of care now includes pain relief. The physician seemed very upset with this, stating that it impaired her assessment of the patient, and that the "ride over here was only 8 minutes" and the patient could wait for pain medicine. She even said that us giving pain medicine makes their "2mg of morphine seem not so great" to the patient.

I tried to answer all of her concerns to the best of my ability. I emphasized the short half-life of fentanyl, the results of my initial physical exam that were completed before pain medicine, that 8 minutes of pain is still 8 minutes of pain, and that the effectiveness of their morphine should only be based on the patient's pain relief. I also tried to bring up the fact that our protocols (for the entire regional system) are based on ER physician recommendations from all of the area hospitals and that she could participate in the working group if she'd like to make recommendations.

In any case, the physician ended up walking away from me in mid-conversation, with nothing resolved.

I have worked with lots of partners who show resistance to treating pain (you all know the type... "the patient doesn't deserve the pain meds", "it's a short trip", etc...) but I have yet to experience this resistance with physicians or hospital staff.

My question to everyone is, does pain medicine actually interfere with physician assessment, should we not be providing pain relief to unknown abdominal/side pain patients, and have you had physician resistance to pain management protocols? And any advice for handling this physician (who has told us before to not start IVs on patients, even those in need of ALS, so they can go out to external triage - aka 'the lobby')?
 
redcrossemt said:
Patient Summary: 26 y/o female with worsening left flank pain over the past 3 days. It has been a 2-3 out of 10, just kind of achy; but this morning is a "20" out of 10, woke patient out of her sleep, and she couldn't get back to sleep because of the pain. Patient was tachycardic, tachypneic, wincing, and generally appeared to be in distress. Interventions included 1.5 mcg/kg of fentanyl IV. Our transport time was about 8 minutes.

After patient care had been transferred and report given to nursing staff, the ER physician took me aside and asked me why I had given fentanyl to this particular patient. I reiterated the story above, emphasizing that the patient said she was in severe pain, and appeared to me to be in distress. I also reiterated our pain management protocol, and that the pre-hospital standard of care now includes pain relief. The physician seemed very upset with this, stating that it impaired her assessment of the patient, and that the "ride over here was only 8 minutes" and the patient could wait for pain medicine. She even said that us giving pain medicine makes their "2mg of morphine seem not so great" to the patient.

I tried to answer all of her concerns to the best of my ability. I emphasized the short half-life of fentanyl, the results of my initial physical exam that were completed before pain medicine, that 8 minutes of pain is still 8 minutes of pain, and that the effectiveness of their morphine should only be based on the patient's pain relief. I also tried to bring up the fact that our protocols (for the entire regional system) are based on ER physician recommendations from all of the area hospitals and that she could participate in the working group if she'd like to make recommendations.

In any case, the physician ended up walking away from me in mid-conversation, with nothing resolved.

I have worked with lots of partners who show resistance to treating pain (you all know the type... "the patient doesn't deserve the pain meds", "it's a short trip", etc...) but I have yet to experience this resistance with physicians or hospital staff.

My question to everyone is, does pain medicine actually interfere with physician assessment, should we not be providing pain relief to unknown abdominal/side pain patients, and have you had physician resistance to pain management protocols? And any advice for handling this physician (who has told us before to not start IVs on patients, even those in need of ALS, so they can go out to external triage - aka 'the lobby')?
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Sounds like a walking lawsuit. So much for higher education, eh?
 
First point: Tough luck to the physician. You're working under your med directors license, not hers. If she doesn't like how something is done and it's in accordance to what your MD accepts, tough noogies, it's not her call. Doesn't want an IV? Start one if you deem necessary. If she keeps complaining, ask her if she's willing to be co-named on the lawsuit for not providing an IV to someone who needed it.



As far as pain control for abd pain, I've spoken to a few Docs and PAs on the matter and they are all pretty much in agreement: Pain meds should not make or break their diagnosis, and should not slow down their assessment. If you deem your pt needs pain control, then do pain control.
 
The clinical guidelines I've read for even abdo pain (classically the pt's that had analgesics withheld) specifically state that pain management does not and should significantly interfere with assessment and in fact, management of pain may make assessment easier as the pt. can focus on and answer questions with regards to their symptoms.

It's unfortunate that such a dated attitude still exists among professionals. Sure we don't want to "snow" our pt.'s, but we can still manage their pain. At the very least titrate for a more manageable pain level.
 
Luckily for me, I'm not on the hook for any pain management decisions my medic makes. But we keep running into one receiving physician who we just can't win with. If we gave pain relief, we're screwing up his assessment. If we didn't--even when the patient doesn't want drugs--we're abusing the patient.
 
One of the main reasons Fentanyl is becoming the prehospital standard of care for pain management is it's short 1/2 life. It gives the crew the ability to transport the patient comfortably and wear off shortly after arrival at the ED, thus allowing the Doc to evaluate the patient. We as paramedics exist not only to treat cardiac arrests, but to prevent patients from suffering through excruciating pain while they are in our care.
 
During my internship; Experienced an learning situation similar but not similar to this one. Basically it was on the use of pain medication for abdominal pain. I'm sure it applies to this patient also.

The article I used involved MS for pain management. But the overall goal is the same. Pain therapy is both prudent and humane to take the edge off (without eliminating pain), in order to reduce the discomfort. Also, the physical assessment alone is not used to diagnose the patient due to the advancement in modern medicine.

View attachment morphinesulfate.pdf
The last portion of this file gives an excellent explanation.
 
Not being a medic, I can't really comment on pain management, other than to say that I have frequently wished there was something I could do for a patient who was in pain. It's a good 15-20 minutes on bumpy roads to a hospital around here, and even the medics generally don't give anything for pain. When you have to lift the patient, put them on the stretcher, load them, and then get them to the hospital, it would be nice - both for me and the patient - if they weren't intermittantly screaming in pain.

And yes, I try to be as gentle as I can, but moving someone with a broken or severely dislocated bone will be painful no matter what I do.
 
I agree that prehospital analgesia is very important and that patients need to recieve adequate analgesia.

That said, lets say this patient was 50kg (50mcg of fentanyl at 1mcg/kg) is equivalent to 5mg of morphine. If she was 50g at this guy'd dose of 1.5mcg/kg that's like 7.5mg of morphine.

If this were me .... I might give her oh, 2mg and titrate up to maybe 5.

I can sort of see where this doc might be a bit pissed I mean was this patient spun off into lalaland or did she tolerate the fentanyl quite well? I mean in general I'll that physicians who think ambo's should not be giving pain relief are idiots but if ambo gets thier patient so wasted they can't participate in exam or treatment then yeah, fair enough.
 
MrBrown said:
I agree that prehospital analgesia is very important and that patients need to recieve adequate analgesia.

That said, lets say this patient was 50kg (50mcg of fentanyl at 1mcg/kg) is equivalent to 5mg of morphine. If she was 50g at this guy'd dose of 1.5mcg/kg that's like 7.5mg of morphine.

If this were me .... I might give her oh, 2mg and titrate up to maybe 5.

I can sort of see where this doc might be a bit pissed I mean was this patient spun off into lalaland or did she tolerate the fentanyl quite well? I mean in general I'll that physicians who think ambo's should not be giving pain relief are idiots but if ambo gets thier patient so wasted they can't participate in exam or treatment then yeah, fair enough.
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I'm not questioning you, but have you ever used fentanyl before? I know they say that fentanyl is 100 times more powerful than morphine, but I've never seen 100mcg of fentanyl compare to the analgesia or sedation properties of 10mg of morphine. In fact, our region's maximum dose increased from 2mcg/kg to 3mcg/kg because we weren't always getting adequate analgesia from 2mcg/kg doses, and the drug was proven to be safe, effective, and well-utilized among paramedics in our region.

Patient in said scenario weighed 60kg. She initially got 60mcg, and got another 30 mcg when her pain was not relieved by the first dose after 10 minutes or so. She tolerated it well and wasn't "wasted" or unable to participate in a continued exam or treatment.
 
Here is a good article about Fentanyl and I thought this line from the article punctuates the OPs issue about ED docs arguing that their assessment his hindered by the use of Fentanyl.

"Also, its short duration of action would appear to be ideal for agencies that still have difficulty with emergency physicians who chastise use of narcotics that may mask symptoms of pain and hide illness or injury despite the overwhelming scientific opinion in the peer-reviewed medical literature that this is a myth."

http://www.emsresponder.com/features/article.jsp?id=6016&siteSection=16
 
Just curious, did you ever find out what was the cause of the pain? I'm thinking it was a kidney stone. I had one and had the same symptoms. They are VERY painful.
 
Matter of fashion and commonsense

1970s: pain meds available at the time would obtund the pt, depress resps. Prehospital analgesia was very limited, second tiered to life support and spinal/ortho stabilization. USe of nitrous oxide suggested.
1980's: much the same. Newer drugs becoming available, paramedics given more latitude using protocols (versus everything by radio order).
1990's: Continuation of 1980's trends. Quality assurance measures increase, including patients having a greater say. Pain control becoming an issue.
2000's: "Pain Control" becomes big time issue, many practitioners ordering scheduled drugs on pt demand. OD's and additions upswing due to use/abuse of valid prescriptions.

Follow your protocols when they do not damage the patients or obtund them. I'd suggest doing your manipulations and spine boarding etc before meds because pain can be the sign you are doing something wrong, and if it is masked you might drive into the ER and find that foreign object in their back, or undx'ed fx that pain would have divulged. Ther's always going to be someone with a bone to pick, just document like crazy and keep an open mind.
 
I wouldn't worry to much about it at this point. "Masking" symptoms with analgesics and creating problems with further assessment has for the most part been shown to be a falsehood; apparently this MD either isn't comfortable with her assessment, still holds to the old belief and not current trends, or doesn't like what you are doing prehospital. The comment about making their treatments seem "not so great" is particularly disturbing. Either way, what you did, including your explanation was the right thing to do. If this continues to be a problem it might be something that needs to be brought up (tactfully) with your medical director, but otherwise, keep treating your pt's like you're doing.
 
My old medical director gave a great explanation on pain management:

He said that in the near past doctors needed the patient totally awake and feeling everything so that the doctor could do a hands on exam: palpatating the abd for kidney stones or r/o appendix. But it wasn't always accurate, if a patients abd hurts, they would say it hurt no matter where they were pushed on.
Now doctors use CT scans to rule them out, and the patient is ok to be "snowed" by pain meds; or just happily pain free.

We were told that if our patient had stubbed their toe, and had a pain level over 3/10 to make it go away by the time they got to the hospital.

And to the earlier poster, yes it is great if your patient doesn't scream every time you touch them. I always hated that when I was BLS,. I had quite a few medics who wouldn't give pain meds.
 
Oh dear...

It's very sad to see that old saw of "analgesia masking symptoms" being trotted out by a Dr who should know better.

This fallacy became popular in the 1920s following the publication of a boom on surgery written by a certain Mr Cope. Cope had no evidence for his statement beyond his own ideas, however this nonsense became very popular over the years.

It has now been demonstrated as patently false following a number of studies (LoVecchio comes to mind, but I cant think of the others). In fact as has been alluded too, removing the affective aspect of pain (the distress) actually makes it easier to assess patients as they are able to better describe symptoms. Add to this the availability of FAST, CT, MRI and all the other wonders of modern technology, and it becomes clear that there is absolutely no need to leave a patient suffering.

You treated the patient appropriately, humanely and within the scope of your practice. You have nothing to answer to, so stick to your guns and keep acting in the best interests of your patient.
 
Found a good literature review on the subject for those interested:

"Effect on diagnostic efficiency of analgesia for undifferentiated abdominal pain"; Thomas and Silen; British Journal of Surgery, Volume 90, Issue 1 (p 5-9).
 
Something that can be borrowed from the sports field is the idea of a tolerable level of pain. Achieving that can take some considerable care in titrating meds. What this achieves is you not blotting out the patient's sensation of pain nor does it just simply "take the edge off". On the pain scale, you're shooting for somewhere between a 1 and 3... For abdominal pain, the patient is still able to localize pain, and probably can localize it much better upon palpation. Snow them, and good luck finding out even IF they're having sympoms... provide no analgesia and they could feel pain no matter what you do.

It also allows the patient to set their own level of tolerable pain. For some, no pain is tolerable. For others, they can tolerate what might be considered great pain. It's very individualized.

Take the pain down to a tolerable level, do the exam, and then blot the pain out.

That philosophy was one I learned prior to getting into Paramedicine and one reinforced during my clinicals.

My impression is that prehospital pain management is still lacking... but it's a far sight better than it was. I, and I'm sure others, recall a time when NO pain management was available in the field outside the setting of MI.
 
the service i ride with carries morphine and fentanyl, we have been instructed to titrate the meds(w fentanyl being preferred by most) until the pt pain is 0...not 1...not 2....0
 
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