Theoretical/Practical Pain Management Question

[Luno]

Ok, let's just say that you have a unaccompanied minor in non-life threatening severe pain, and an inability to contact any parent/guardian. Transport to definitive care is in excess of 30 minutes, and you don't have an ambulance at hand, but you can request one within 10 minutes. Now because you have to send the patient by 3rd party, you may/may not be able to use that ambulance, depending if you decide to mitigate pain. And you might have to wait 40 minutes for an ambulance that will accept a patient with pain control measures on board. What is your plan?

Now let's just assume that you have at your disposal whatever pain management your agency uses.

Some key issues to understand
-implied consent
-necessity of treatment
-reliability of witness
-possibility unknown drug reaction/interaction
-parent's concerns

Before you answer, understand that this is entirely hypothetical, but a very loaded issue, and deals with alot of what we've been discussing lately as far as pain management as a "necessary" treatment and function of ALS.

I've given you the topic, discuss amongst yourselves, I'm all verclempt...

 

[EpiEMS]

I can't see why you wouldn't treat the patient.

"In addition to life- or limb-threatening conditions, the legal definition of an EMC may include conditions with severe pain or conditions with the potential for serious impairment or dysfunction if left untreated." -- from this AAP statement endorsed by NAEMSP as well. Pages 430 to 431 under the heading "Prehospital Consent" is what seems to be most relevant to EMS.

I think it bears mention that a 16 year old patient unaccompanied by a parent/guardian is going to be treated differently than an 8 year old patient, say, regarding knowing about allergies and those sorts of things.

 

[Carlos Danger]

I don't think it's a loaded issue or a complicated one; I think there is only 1 answer and it's fairly obvious: treat the pain under implied consent.

Anyone who refuses to treat a person in severe pain because they don't want to ride 30 minutes to the hospital with them seriously needs to find another line of work.

 

[Luno]

I warned you...

I don't think it's a loaded issue or a complicated one; I think there is only 1 answer and it's fairly obvious: treat the pain under implied consent.

Anyone who refuses to treat a person in severe pain because they don't want to ride 30 minutes to the hospital with them seriously needs to find another line of work.

"you don't have an ambulance at hand, but you can request one within 10 minutes. Now because you have to send the patient by 3rd party, you may/may not be able to use that ambulance, depending if you decide to mitigate pain."

You don't have the option to transport, if you mitigate pain, you are delaying the patient's transport of 30 minutes to 40 minutes for an appropriate resource to respond, and 30 minutes of transport... So possibly by mitigating pain, you have caused at a minimum an additional 40 minute of time before the patient can even be moved...

Anyone who refuses to treat a person in severe pain because they don't want to ride 30 minutes to the hospital with them seriously needs to find another line of work.

Perhaps I didn't make it clear, but you cannot transport this patient.

 

[Carlos Danger]

you don't have an ambulance at hand, but you can request one within 10 minutes.

And you might have to wait 40 minutes for an ambulance that will accept a patient with pain control measures on board.

This doesn't mean you have have an ambulance available?

If you have no way to transport the patient, why were you even dispatched to the request?

 

[Veneficus]

Unless you came on a motorcycle, happened to be hiking through the woods, or parachuted out of a plane, you probably have a way to transport.

It might not be in a designated "ambulance," but aside from looks and comfort, their is not really much difference having somebody slumped in a back seat vs laying supine on a cot when it comes to ability to transport.

In remote medicine, it is not uncommon to medicate people and put them on a civilian commercial flight. With or without a medical escort. I don't see any problem with medicating somebody and shipping them out.

Opposed to what? Not medicating them and shipping them out? In that example, they run an easily mitigatable risk of medication reaction for a definite prolongation of pathology from pain.

If they are at risk of life and limb, you won't be sitting on them waiting for an ambulance anyway. If they are not at risk of such what is the harm in keeping them an extra 20-30 minutes to make sure they are properly medicated and stable?

 

[Luno]

I warned you this was more complicated than it seemed when you first read it... I will fill in the back story in two weeks. This is an interesting "theoretical" case.

 

[usalsfyre]

This seems like one of those one off cases you run across on occasion. You can't let the outlier affect policy or standard of care too much.

It also smacks of people making things more complicated than they have to be.

Treat the pain. Don't bother with the wishy washy truck and call the advanced unit. If the 10 min away truck can't do what's needed there's no point in tying that resource up. If the pain is adequately medicated you've got a few minutes and the few minute delay is not a huge deal to anyone other than the provider.

I think a few more people need to be an EMS patient in severe pain before they make their decisions on the necessity of pain management.

 

[Luno]

the rest of the story

Ok, it's a little past 2 weeks, but here's the situation, so this is a prehospital question posed by physicians, reflecting an actual case that is currently being discussed among this group both for medical (pain management as a necessity) and ethical (limits of implied consent). I find it interesting that often the call is both for additional education and scope for paramedics, but this is a relatively simple solution for prehospital but becomes an entirely different level of question when brought to the MD level...

 

[Rialaigh]

So if you provide pain management you are delaying physician care by 40 minutes in addition to treating something not life threatening on a minor with only implied consent.


Honestly I think you run the risk of getting sued in the US.


Easy solution. Require online medical control to provide pain management to minors with implied consent in non life threatening situations when the PT is conscious.

 

[Handsome Robb]

So if you provide pain management you are delaying physician care by 40 minutes in addition to treating something not life threatening on a minor with only implied consent.


Honestly I think you run the risk of getting sued in the US.


Easy solution. Require online medical control to provide pain management to minors with implied consent in non life threatening situations when the PT is conscious.

I understand we live in a litigious society but I see no way anyone could make a case against you in this instance.

It's been specifically presented as non life/limb threatening.

I'd be more inclined to sue an ambulance service that did not treat my son or daughter's severe pain.

It's implied consent, you made reasonable effort to contact a guardian and were unable to, the patient cannot make decisions for him or herself. If they don't want to go then, in my system, pd is getting involved and taking them into temporary custody so we can transport them. If we were going down that route I wouldn't personally medicate them but if the patient was cooperating and agreeing to be transported (even though legally they can't make that choice) I absolutely would call the ALS resource and medicated the patient appropriately.

Question? Why can't we call the closer resource and ride in with the patient in the back of the BLS ambulance instead of waiting for another ALS resource? The way this is presented I'm assuming the provider on scene was a medic...why can't s/he ride in in the closer ambulance? I'm sure the answers going to be "you can't leave your current location" because of some TEMS or Special Event since it's Luno that started this

I don't need a doctor to tell me yes or no when it comes to providing analgesia. There's another reason right there why we aren't respected as a profession, we're too afraid to make decisions for ourselves. I understand sometimes you have to call, either to deviate from protocol or for advice but I know for a fact most of the physicians here would laugh you out of your socks and your job if you called them for orders in this situation.

 

[Dwindlin]

I'd be more inclined to sue an ambulance service that did not treat my son or daughter's severe pain.

You are a reasonable person (I assume), the same cannot be said for the vast majority of people who bring suit against the medical profession.

 

[Veneficus]

You are a reasonable person (I assume), the same cannot be said for the vast majority of people who bring suit against the medical profession.

I think the reason a vast majority bring suit is because they feel wronged.

We have to admit that medicine has become so industrial and machine like, patients aren't kept informed, adequte time is not spent with them, individual attention is almost non existant, and rather than try to address these issues, the medical community (everywhere) feels that increased testing and hyperspecialized treatment will somehow stop people from suing without addressing the root causes.

(not to say these are the only causes)

However, if you look at how people actually respond when they are well treated, and how little they actually care about diagnostics and treatment compared to being treated nicely, I think it is obvious that many more lawsuits could be avoided by compassion than by increased medical sending for defense.

How often have you seen providers treat various social-economic class patients like dirt?

Since there are actual studies linking socio-economic status to care received, I would not believe you if you tell me you didn't.

This treatment builds resentment.

One of my former teachers always liked to say:

"Make every patient your friend. You would never sue your friend. You would gladly sue your enemy."

In my opinion, everytime you treat the psych hold, addict, frequent flyer, or person you don't believe is deserving of care or acertain level of care, poorly you make an enemy.

 

[Rialaigh]

I understand we live in a litigious society but I see no way anyone could make a case against you in this instance.

It's been specifically presented as non life/limb threatening.

I'd be more inclined to sue an ambulance service that did not treat my son or daughter's severe pain.

It's implied consent, you made reasonable effort to contact a guardian and were unable to, the patient cannot make decisions for him or herself. If they don't want to go then, in my system, pd is getting involved and taking them into temporary custody so we can transport them. If we were going down that route I wouldn't personally medicate them but if the patient was cooperating and agreeing to be transported (even though legally they can't make that choice) I absolutely would call the ALS resource and medicated the patient appropriately.

Question? Why can't we call the closer resource and ride in with the patient in the back of the BLS ambulance instead of waiting for another ALS resource? The way this is presented I'm assuming the provider on scene was a medic...why can't s/he ride in in the closer ambulance? I'm sure the answers going to be "you can't leave your current location" because of some TEMS or Special Event since it's Luno that started this

I don't need a doctor to tell me yes or no when it comes to providing analgesia. There's another reason right there why we aren't respected as a profession, we're too afraid to make decisions for ourselves. I understand sometimes you have to call, either to deviate from protocol or for advice but I know for a fact most of the physicians here would laugh you out of your socks and your job if you called them for orders in this situation.

Lets approach this from the angle of not limb or life threatening.

The first thing that I found from google after a 30 second search is from the Connecticut General Assembly from 1995. I am guessing however that most state laws look this way. I am sure with a little work I could find something more pertinant to EMS


"The traditional common law view was that a minor child could not consent to medical or surgical treatment. A physician was obliged to get the consent of the child's parent or someone standing in place of the parent. The only acceptable exception was an emergency when it was either impractical to obtain parental consent or any delay would unduly endanger the patient's life. Case law on this subject strongly supports this exception; courts hearing such cases often broadly define medical emergencies. In medical emergency cases, the courts have discussed an implied consent to treatment. Permission by the parents or guardian for medical or surgical care is implied by the law, assuming that had the parents known of the situation, they would have authorized treatment. The more urgent the circumstances, the more likely that the courts will find a basis for implied consent. Generally, the issue is examined on a case-by-case basis (see Rozovsky, “Consent to Treatment, A Practical Guide”).

Connecticut law is not particularly detailed concerning the issue of parental consent for the routine or emergency examination of a minor. The public health code provides that “it shall be the responsibility of each hospital to assure that the bylaws or rules and regulations of the medical staff include the requirement that, except in emergency situations, the responsible physical shall obtain proper informed consent as a prerequisite to any procedure or treatment for which it is appropriate (Public Health Code, § 19-13-D3(d)(8)). The law does not address the ability of “grandparents” to give consent."


Obviously talking about a hospital setting but it explicitly states "except in emergency situations" you must receive informed consent as appropriate for any treatment or procedure. We must generally have to receive informed consent when treating an adult. And implied consent comes into play for making "emergency" interventions when the patient is unable to make decisions for themselves.

Unless the pain for this child is affecting the ability to treat the underlying cause, or is negatively affecting their vital signs. I think you are on iffy legal ground.

 

[Dwindlin]

I think the reason a vast majority bring suit is because they feel wronged.

We have to admit that medicine has become so industrial and machine like, patients aren't kept informed, adequte time is not spent with them, individual attention is almost non existant, and rather than try to address these issues, the medical community (everywhere) feels that increased testing and hyperspecialized treatment will somehow stop people from suing without addressing the root causes.

(not to say these are the only causes)

However, if you look at how people actually respond when they are well treated, and how little they actually care about diagnostics and treatment compared to being treated nicely, I think it is obvious that many more lawsuits could be avoided by compassion than by increased medical sending for defense.

How often have you seen providers treat various social-economic class patients like dirt?

Since there are actual studies linking socio-economic status to care received, I would not believe you if you tell me you didn't.

This treatment builds resentment.

One of my former teachers always liked to say:

"Make every patient your friend. You would never sue your friend. You would gladly sue your enemy."

In my opinion, everytime you treat the psych hold, addict, frequent flyer, or person you don't believe is deserving of care or acertain level of care, poorly you make an enemy.

I absolutely do agree that patients who like their provider are less likely to sue, but my point doesn't change, the vast majority of suits are unreasonable, brought forth by unreasonable people. A topic for another thread though. . .

 

[Rialaigh]

Idk, this is a very grey area. I guess an argument could be made that implied consent allows you to treat the patient (even in a non-emergent manner). My issue is that fact that "treating" the patient for pain (providing pain management) is delaying treatment by a physician. I think that is the bigger issue in this specific case. However this is interesting.

 

[Luno]

@Rialaigh, very interesting cited Code, especially since the prehospital providers were physicians.

 

[Rialaigh]

@Rialaigh, very interesting cited Code, especially since the prehospital providers were physicians.

I haven't bothered to try and find anything current on the internet but I am betting there are various codes depending on whether it is done in a medical facility or in the field.

I would bet different standards apply to physicians and paramedics as well.

We had a great discussion on my class forum on whether a minor could refuse transport and in what situations they could or could not. Not sure if you would be interested in that discussion (as it goes hand in hand with a minor refusing or accepting treatment).

 

[Luno]

Absolutely, especially since this scenario hinges on whether mitigating non-life threatening pain is applicable under implied consent, and the resulting risks of not having a complete medical history, the transport decision is another side issue that was thrown in due to a unique environment...

 

[Veneficus]

Absolutely, especially since this scenario hinges on whether mitigating non-life threatening pain is applicable under implied consent, and the resulting risks of not having a complete medical history, the transport decision is another side issue that was thrown in due to a unique environment...

I don't think it is as simple as "non-life threatening pain" I think it is more in the realm of would a reasonable person expect care.

Let me complicate the example.

If a teenage baby sitter brings a minor into a healthcare facilty with a nonlife threatening injury or illness, like vomiting, or perhaps a laceration benefical from suturing, etc, and the parents cannot be contacted for whaever reason, we don't bounce those people out the door or make them wait. (Usually it is a grandparent or somebody else without "legal" guardianship other than being a relative)

We use implied consent as cover for what a reasonable person in such a situation would want.

People don't need sutures emergently. People do not often need antibiotics or a prescription for such that moment. They don't even likely need a medical eval.

Not having a complete history is also bogus in my opinion. I often do not have a complete or any history at all. BUt I don't have a seizure and then stop taking care of the patient.

I am also a little unsure about the idea of using pain as a non-life threatening condition delaying an MD evaluation.

How many agencies begin treatment of chest pain on scene? How many of you will not begin treatment of chest pain on scene for the purpose of driving to the hospital first to shorted time to an MD evaluation?

In many cases whether or not that chest pain is life threateneing or not is known after the fact, not when you are treating it.

GO ahead and tell me that if you had an elderly lady complaining of chest pain and the 12 lead didn't show a STEMI that you would sit on your hands until a doctor looked at her and somebody ran a troponin.

Pain is a medical condition unto itself. Without cell damage, there is no pain.

Deciding against treating somebody to the best of one's ability because the patient is "not emegergent" sounds like a an excuse not to get involved raher than a legal question to me.

Certainly it is a half-assed job.

It sounds in this instance it would be better to remove the MD from initial contact and make it an EMS only poperation.