[Separated] Give drugs to drug seekers

[epipusher]

I believe in the statement that it is not our place to be judging our patients. Some may respond by saying they are not judging, but using "clinical judgement". In my opinion, that is complete horse manure. Flame away.

 

[usalsfyre]

Your talking about cultural differences in perception of pain I'm guessing?

It's well established different cultures have different levels of pain tolerance and some may remain more stoic. While it's an interesting broad generalization, at the end of the day pain perception (and therefore analgesia) is still an individual sport.

 

[usalsfyre]

I believe in the statement that it is not our place to be judging our patients. Some may respond by saying they are not judging, but using "clinical judgement". In my opinion, that is complete horse manure. Flame away.

Then a whole lot of chronic pain management specialists are full of equine puckey...

Like I said, I'm a fairly radical proponent of field analgesia. Even patients that I'm sure are seeking (the guy who's popped his hip out for the 8th time this month) get analgesia. If there's any doubt, give the meds, that morphine or fent isn't costing you anything.

That said...at some point there's a line. Treating conditions that are better taken care of with NSAIDs or APAP (the stubbed toe, minor headache, ect) with IV narcotics because we don't have another option is as inappropriate as withholding pain meds to an open fracture.

 

[DrankTheKoolaid]

That said...at some point there's a line. Treating conditions that are better taken care of with NSAIDs or APAP (the stubbed toe, minor headache, ect) with IV narcotics because we don't have another option is as inappropriate as withholding pain meds to an open fracture.

This absolutely is our problem.. Would love to get some Toradol on the trucks!

But for those interested in pain management give Soto's book a read. This goes way beyond generalizations and for the redhead it goes into cellular level why they react and feel pain differently.

 

[triemal04]

I believe in the statement that it is not our place to be judging our patients. Some may respond by saying they are not judging, but using "clinical judgement". In my opinion, that is complete horse manure. Flame away.

Fair enough, and I agree completely with you. Of course, I hope that you aren't some sort of hypocrite, and whenever someone tells you that they are short of breath you use every single medicine that you have available for respiratory issues to treat them. All of them. For every respiratory issue. After all, trying to determine what the cause of their complaint was and if they even have a valid complaint isn't using clincal judgement, it's judging someone. And that's wrong.

Do you see how silly that is?

It's shocking how often this arguement comes up here, despite how few times I've had to argue about it in real life. So, either I work with a truly elite group of paramedics (yeah...not completely true), nobody gives narcotics where I work (given how often the drug log get's updated that isn't the case) or most people have figured out something that is lacking here.

Saying that everyone who complains of pain will get treated for said pain indiscriminantly is no different than indiscriminently treating a complaint of SOB as above, or giving every single person complaining of chest pain nitro...:rofl:... To decide if someone needs a narcotic is no different than deciding if someone needs albuterol or nitro or versed or magnesium or amiodarone or dopamine or epinephrine; it is our job to determine what treatement a patient needs based on our assessment and, yes, judgement of what is happening. That does not mean judgement on a personal/socioeconomic level, but just focused on what the medical issue is. Even a spineless protocol monkey can do that; they still have to decide which protocol they'll be blindly following.

If you aren't capable of doing that, then you should not be in a position where you have to make decisions about someone's care. Period. That's really what is always so disturbing about this thread when it repeats itself; people are argueing that you should mindlessly treat people without thinking...why does that sound like a bad idea?

If someone is blatantly drug seeking then no, they don't get narcotics. If someone is in pain then they get treated until they aren't in pain anymore. If you aren't sure because you actually assessed the patient and still can't tell if there really is a cause for their complaints...then they get narcotics, or whatever you may carry for pain relief. See how simple that is?

Of course, at some point you'll be wrong if you do it like that, both in giving meds and withholding them. Hopefully not very often, but it will happen. But then...you'll also be wrong some of the times you give other medications, or choose not to give them.

 

[epipusher]

You're comparing apples to oranges.

 

[usalsfyre]

You're comparing apples to oranges.

Perhaps the same way your taking an overly dogmatic argument to the extreme?

 

[epipusher]

Perhaps the same way your taking an overly dogmatic argument to the extreme?

Agreed. I do not see the problem in treating my patients with pain meds who complain of having said pain. Two major reasons: One being, if I deem them a bs, a frequent flier, or insert your own term, me not giving them pain meds on this particular run are not gonna keep them from calling again. Two, back to the whole being non-judgemental approach, who am I to say that this time their pain is not legit.

 

[usalsfyre]

Agreed. I do not see the problem in treating my patients with pain meds who complain of having said pain. Two major reasons: One being, if I deem them a bs, a frequent flier, or insert your own term, me not giving them pain meds on this particular run are not gonna keep them from calling again. Two, back to the whole being non-judgemental approach, who am I to say that this time their pain is not legit.

What about the inappropriateness of

1)chronic pain management by EM?

2)Treating relatively minor complaints with IV narcotics?

 

[epipusher]

2)Treating relatively minor complaints with IV narcotics?

Is this your opinion and dx of it being a relatively minor complaint? For me, if it is a minor complaint but the pain is rated by the pt of at least a 3/10, then I would be treating the pain relief.

 

[triemal04]

You're comparing apples to oranges.

Not really, no.

When someone presents to you with a complaint about their health, your job is to assess them, and then using your clinical judgement as you put it, treat them to the best of your abilities, based on your determination of what is wrong. It doesn't matter if the complaint is "my head hurts" or "I can't breathe," to mindlessly start giving medicine is not appropriate. It may be easier to assess one complaint than the other, and it may not be possible to be certain about one or the other, but it is still your job to make a decision based on your assessment and exam.

If your decision is to not bother because it's easier, then you shouldn't be making any decisions about how to treat someone. And doing what you advocate is taking the easy way out, it's not a humane or nice decision, it's a cop out. Sorry, but it is that simple.

 

[triemal04]

For me, if it is a minor complaint but the pain is rated by the pt of at least a 3/10, then I would be treating the pain relief.

So it's all just treating a number then?

Don't think, just do whatever the numbers say you should?

Wow...

 

[epipusher]

And if my assessment and exam reveals the patient is having pain, I am giving them pain medication. My original point is that I am performing this assessment, evaluation and exam and treatment regardless if they are a known drug seeker or a frequent flier.

 

[usalsfyre]

Is this your opinion and dx of it being a relatively minor complaint? For me, if it is a minor complaint but the pain is rated by the pt of at least a 3/10, then I would be treating the pain relief.

Minor orthopedic injuries are, by definition, minor

Most dental complaints are minor.

Non-migrane, non-hemorrhagic, non-ischemic headaches are minor.

Muscoskeletal pain in a young adult related to a chest infection is minor.

Your not going to get push back from anywhere calling these complaints minor (and spare the "patient defines" rigamarole, if that were 100% true there'd be no triage). Each of these complaints is far more appropriately managed via non-narcotics or PO narcotics at the extreme end of things than via IV narcotics.

As I've stated, I'm a huge advocate of analgesia for professional and personal reasons. But, irresponsible use of opiates isn't the answer either.

 

[epipusher]

So it's all just treating a number then?

Don't think, just do whatever the numbers say you should?

Wow...

yes essentially, as our protocols state and our medical directors continually point out in audit and reviews of these particular runs. We of course, as do everyone, have to take into account LOC, allergies/sensitivities, consent, etc.

 

[epipusher]

usal, i completely understand your post. I am just stating my reasoning for my way of treatment for those examples of patients you have listed.

 

[usalsfyre]

usal, i completely understand your post. I am just stating my reasoning for my way of treatment for those examples of patients you have listed.

Sounds like you've got the same issue as the rest of us in US EMS, IV narcs or no analgesia at all. Makes me :wacko:.

 

[triemal04]

And if my assessment and exam reveals the patient is having pain, I am giving them pain medication. My original point is that I am performing this assessment, evaluation and exam and treatment regardless if they are a known drug seeker or a frequent flier.

I absolutely agree with the bolded portion. Not doing so is no different than blatantly handing out meds without thinking. But you have to really do the first part of that sentence before you can get to the last part.

What I take issue with is what you said above. "the pain is rated by the pt of at least a 3/10, then I would be treating the pain relief" That's not thinking about what you are doing, that's following a cookbook. That's not an assessment, that's a cop out.

 

[epipusher]

Alot of times it is an absolute cop out. Not to sound corny, but I could change cop out to saying its a "keep out" of the Quality Assurance Chiefs office.

 

[epipusher]

I've had similar discussions before where our fellow coworkers and I realized a lot of what we do is cya and a "cop out" to keep "under the radar" of our QA personnel