Physicians' Impression of Pre-Hospital Pain Management

[spikestac211]

OP: So what was it, kidney stone?

 

[BLSBoy]

We are there to treat pain, but sometimes its a double edged sword because you gotta worry about BP.

With Fent, it doesn't have as much of a response on the BP that Morphine would.

 

[FLEMTP]

I think overall, fentanyl is a better medication for pain management, prehospital any how.. and it is very versatile in its uses.. since many agencies also use it for either pre or post medication/analgesia for drug assisted intubation

I do think that morphine should still be carried as an alternative in the case of allergies, or prolonged transports, or in situations where a slight decrease in blood pressure would be to the patient's benefit.

Also, im not sure, only because I havent personally seen any studies, but does phenergan potentiate fentanyl like it does morphine? Sometimes I prefer to give a patient morphine with phenergan together, ie: abdominal pain with nausea/vomiting... or with a nauseaed/vomiting chest pain/cardiac patient.

 

[fire_911medic]

Pain Management

Here we are very fortunate regarding docs supporting us with pain management, and I have seen medics disciplined by the docs for not giving pain meds due to some of the reasons stated (short trip, didn't think they needed them, etc). It may be a short trip, but many times, especially in a busy ER or if seriously injured, many things will take precedence over giving pain meds and the patient will sit on a backboard or in a stretcher for quite a while uncomfortable. Be proactive with pain management. If a patient tells you they are in pain, it is your responsibility to attempt to alleviate that pain. I am very considerate with pain meds as I know what it's like to be in the patient's shoes and sitting around in extreme pain while you're waiting for someone to get to you, so I think that forms my opinion and shapes the way I practice a bit more than someone who's not been in that position. I've had docs fuss at me a few times, but rarely. My response always is the same - my patient complained of pain, and it's not my job to determine whether that pain is real or not - they qualified and quantified their pain, and I worked within my protocols to relieve that pain. I've never had them question that response.

 

[grich242]

My point is that we need to progress further! It's a sad day in my book when a physician is withholding pain medication for abdominal pain, when the paramedics know the research is there to support it and have the protocols to do it.

Sorry I got cut off and didn't finish I also wanted to add that that is not the attitude shared in large by the md's at the 4 er's that I work out of. Its out dated and the protocols were changed in many ways to allow us the freedom to practice those skills like pain management as we are trained and licensed to do. We continue to push to make improvements to provide better care and system wide improvements. It helps when medics provide good competent care and arguments like hers will fall on deaf ears, as far as med control goes. so ignore her and continue to provide care.

 

[Aidey]

I think overall, fentanyl is a better medication for pain management, prehospital any how.. and it is very versatile in its uses.. since many agencies also use it for either pre or post medication/analgesia for drug assisted intubation

Myself and most of the other medics I work with are not fans of fentanyl. For some things it works well, but for orthopedic injuries I've never had a good response to it, even giving large doses.

 

[reaper]

I have seen the exact opposite. On Ortho injuries, Fentanyl is rapid onset and much better pain relief then Morphine. These are the results I have seen. Most pt's have almost full relief with 50mcg, some need 100 mcg.

 

[Aidey]

Interesting. I've had to max out people to make a significant dent in their pain levels.

This is an example of what seems to happen.

Person with pain 8/10 gets 25mcg, pain goes down to a 7. Another 25mcg. Nothing. Another 25mcg. Nothing. Another 25mcg. Pain drops to a 5/10.

 

[reaper]

What was the time intervals between doses? Fentanyl has a short half life. So if you were 10 minutes between doses, they were only getting 25 mcg at a time. That would not affect pain greatly. I always start at 50mcg and sometimes start at 100mcg, depending on the pt.

 

[SammyGirlMedic]

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.

Medication affects everyone differently. I had a 50kg patient to whom I gave 50mcg of Fentanyl. It did nothing. I gave her another 50 mcg and it "took the edge off" but she actually seemed rather ticked off like she was thinking to herself, "oh thanks for nothing for my tib/fib fx!"
In another instance, a fellow paramedic, who weighs a good 140kg was completely snowed from the 150mcg he got in the ED for a headache he had while having a stroke.

Plus everyone's personal perception of pain is different. Some people are wimps and others can handle it! ;-)

 

[usalsfyre]

My experince with Fentanyl is that it is better to front load with a large dose (1-2 mcg/kg) and follow up with smaller maintnance doses for breakthrough pain at 10-15min intervals. It's not a med that I've seen work well in 25-50mcg doses.

 

[SammyGirlMedic]

My experince with Fentanyl is that it is better to front load with a large dose (1-2 mcg/kg) and follow up with smaller maintnance doses for breakthrough pain at 10-15min intervals. It's not a med that I've seen work well in 25-50mcg doses.

Makes sense.
My little old lady weighing 50kg only got 50mcg because our dose is only 1mcg/kg.. granted I can call in for more, but they won't let me front load with the 2mcg/kg.. they'll tell me to give more only if I tried the 1mcg/kg first. Crappy.

 

[Veneficus]

Makes sense.
My little old lady weighing 50kg only got 50mcg because our dose is only 1mcg/kg.. granted I can call in for more, but they won't let me front load with the 2mcg/kg.. they'll tell me to give more only if I tried the 1mcg/kg first. Crappy.

Is your med control out of St. Es?

 

[Aidey]

What was the time intervals between doses? Fentanyl has a short half life. So if you were 10 minutes between doses, they were only getting 25 mcg at a time. That would not affect pain greatly. I always start at 50mcg and sometimes start at 100mcg, depending on the pt.

My example was what has happened on several calls, so I couldn't tell you exactly what the dosing interval was. I know that I try and keep it short because of the 1/2 life, but like I said, I don't remember specifics.

My experince with Fentanyl is that it is better to front load with a large dose (1-2 mcg/kg) and follow up with smaller maintnance doses for breakthrough pain at 10-15min intervals. It's not a med that I've seen work well in 25-50mcg doses.

Unfortunately we can't do this. A Fire-medic gave a tiny old woman a large dose up front and when she developed respiratory depression he promptly forgot that we carry narcan....

I don't remember if she died or not, but the situation wasn't pretty. We (both the fire medics and the private service medics) are restricted to pretty low doses. No more than .5mcg/kg tops.

 

[usalsfyre]

No more than .5mcg/kg tops.

That's a problem. I very rarely gave less than 100mcgs a first dose, with 50-100mcg follow up doses.

 

[Aidey]

Yeah.....the whole situation is stupid. Everyone was punished because one fire medic lost his head when he overdosed the patient. There were so many other things they could have done first, such as remedial training, but they jumped straight to rewriting the protocols. They actually prefer we start with .25mcg/kg, but we can give a max of .5mcg/kg at once.

 

[zmedic]

Our dose was 1-2mcg/kg. Most people drew up 1mcg/kg and saw the effect, then pushed another dose if needed.

 

[SammyGirlMedic]

Is your med control out of St. Es?

Nope

 

[rhan101277]

I know I am bringing up an old thread, but I gave pain medication the other day to a pt who had C/C of fell three days ago. Pt. states re-injured right ankle doing housework today, right little toe is rotated. It is tender to the touch and swollen. Pt reports pain 8/10; also has a hx of chronic back pain. Pt reports only given 3 days of pain meds and it now out and couldn't sleep last night due to pain These chronic pain patients may/may not not present with HTN or tachycardic, tachypneic.

Anyhow I get to ER and I am told by physician that it was "a little over the top" to start an IV and give morphine. Turns out pt had been prescribed plenty of pain meds and was probably drug seeking. I refuse to get into the mind set that every patient that I encounter who is in pain can just tough it out till the hospital, since they are probably lying to me anyway. I am not there to pass judgment, they initiated EMS system so I am there to help.

Maybe I should bring one of those magic 8 balls and use it after I ask each question to determine whether my pt is lying or what not.

Physician ordered IV taken out and pt sent to waiting room in wheelchair. Physician was not irate or anything but still, I am going to continue to follow protocols and if pain management is warranted I am going to do so.

 

[jwk]

I know I am bringing up an old thread, but I gave pain medication the other day to a pt who had C/C of fell three days ago. Pt. states re-injured right ankle doing housework today, right little toe is rotated. It is tender to the touch and swollen. Pt reports pain 8/10; also has a hx of chronic back pain. Pt reports only given 3 days of pain meds and it now out and couldn't sleep last night due to pain These chronic pain patients may/may not not present with HTN or tachycardic, tachypneic.

Anyhow I get to ER and I am told by physician that it was "a little over the top" to start an IV and give morphine. Turns out pt had been prescribed plenty of pain meds and was probably drug seeking. I refuse to get into the mind set that every patient that I encounter who is in pain can just tough it out till the hospital, since they are probably lying to me anyway. I am not there to pass judgment, they initiated EMS system so I am there to help.

Maybe I should bring one of those magic 8 balls and use it after I ask each question to determine whether my pt is lying or what not.

Physician ordered IV taken out and pt sent to waiting room in wheelchair. Physician was not irate or anything but still, I am going to continue to follow protocols and if pain management is warranted I am going to do so.

Something is missing here. You said they had a 3-day supply of pain meds - for what, from where? That sounds like an ER prescription, and the patient was supposed to follow up with their PMD or perhaps orthopod after their initial injury. It sounds like they didn't do that.