Toradol

[TheLocalMedic]

I think I would give the morphine. It would be better than them pooping on my cot

No. Just... No. I'd rather them poop than hand out morphine just because they ask. Any day.

Excuse me for getting a bit upset when I see jack@ssery such as this. Is it OK for your lawyer to engage in unethical practices? Your accountant? Physician? If not then what makes paramedics special?

Bear in mind that what I was talking about wasn't an outright lie, it was more a sleight of hand. These are "patients" that even the hospital refuses to deal with, they'll give them their free "screening exam" and boot 'em right back out the door. These guys actively seek us out, they walk right up to us and ask flat out for morphine and then pitch a fit when you refuse and then play sick and demand a ride to the hospital. The cops won't deal with them because they "aren't breaking any laws", and if you simply refuse to deal with them and walk away there are a few that are smart enough to try and lawyer up and sue you. I won't go so far as to say they're just "bad people", but it'll be a cold day in hell when I give someone a narcotic just because they want one.

Why not? How in Hades do YOU know if the patient is in pain? What skin is it off off your nose? Are you qualified enough in addiction medicine to diagnose an addiction problem vs legit pain? If it's a system abuser, see below.

See above. I can tell you for an absolute fact that the people that I referenced are not in pain unless it's from withdrawl symptoms, for which I will give them a ride, but not morphine. Also, the skin off my nose comes from the QI process where they start questioning your practice of giving narcs to known system abusers without a good reason. And yes, I have taken courses about addiction problems and addiction treatment. You aren't doing anyone any favors by being the "candy man".

Perhaps your system should look into ways of dealing with system abusers BEFORE this becomes a problem rather than at the site of the call. The appropriate time to make these decisions is NOT at bedside. Get a hold of MedStar in Fort Worth for a good program.

Unfortunately, the best places for most of these "frequent flyers" is either an inpatient addiction treatment center or a psych hospital. The nearest psych facility is about two hours away and only takes patients from the justice system who are criminal offenders, other than that I don't know of any place for them to be sent, it's not uncommon for people on a 5150 to ride out their entire 72 hour hold right in the ER. And you can't "force" someone to seek treatment for their drug abuse problems, so good luck trying to talk these folks into going to a rehab center.

Look, I think that you all are missing the point here.

I never proposed actually lying to a patient, just making a big show out of drawing up and administering saline. If a patient is in actual pain, far be it from me to say "hold the morphine", I think that pain is actually undertreated in EMS and believe that people shouldn't be so begrudging with their drugs. But that's for patients who are really in pain. I do not consider someone walking up to me (in no distress at all) and asking me for morphine to be a valid excuse for administering a narc. Ask anyone and they'll tell you the same. If they want a ride, I'll give 'em a ride. I'll even check their vitals and ask a few questions just to confirm that there isn't anything they need. But if there is no reason to give a drug, you don't give the drug. If someone walked up to you and asked for a dose of epi, would you give it? According to your earlier response, is assume your answer would be, "Well, I guess I can give you some epi. I don't know why I would, but since you asked, far be it from me to say no..."

 

[TheLocalMedic]

Sorry, but I'm going to agree with usalsfyre on this one. It's HIGHLY unethical to engage in such behavior. The argument of whether or not it's ethical for the "system abuser" to engage in behavior you condemn is irrelevant, they're not expected to be ethical, we are. Be proactive and find a way to deal with system abusers in an ethical way or treat them like a first time patient, there's no middle ground for pseudo-treatments that compromise the integrity of our profession. I have never, and will never falsify my treatments...but I guess I value a good nights sleep more than some others.

Oh thou high and mighty. Thou that knowest all. How exactly dost thou propose I "deal with system abusers". The reason why they're called "system abusers" is because they are incorrigible. And would you treat they guy you just brought in to the ER 30 minutes ago like a "fist time patient"? Oh, now his vague "all over" pain is even more all over and even more vague? Well, I guess I should pretend that I don't know he's used this same line on me every shift I've worked for the last four years and give him some morphine.

Look, all I'm saying is that it makes all the other medics look back when you keep giving malingering patients unnecessary treatments. I get a good nights sleep by knowing that I am smart enough to treat my patients appropriately, even if that means withholding treatment.

 

[fast65]

Oh thou high and mighty. Thou that knowest all. How exactly dost thou propose I "deal with system abusers". The reason why they're called "system abusers" is because they are incorrigible. And would you treat they guy you just brought in to the ER 30 minutes ago like a "fist time patient"? Oh, now his vague "all over" pain is even more all over and even more vague? Well, I guess I should pretend that I don't know he's used this same line on me every shift I've worked for the last four years and give him some morphine.

Look, all I'm saying is that it makes all the other medics look back when you keep giving malingering patients unnecessary treatments. I get a good nights sleep by knowing that I am smart enough to treat my patients appropriately, even if that means withholding treatment.

If voicing my opinion makes me a high and mighty know it all, then so be it. I'm no paragod, but if that's you're opinion of me then I'm alright with that.

Yes, I would treat him as a first time patient, however, I don't give all my patients who complain of "all over body pain" narcotics. I'm selective of who gets narcotics from me, and if someone is able to pull one over on me to get narcotics, then I'm alright with that. If I have a "system abuser" who does it frequently then I guess I won't treat them as a first time patient, and I apologize for being hypocritical. However, I WILL NOT give them fake treatments, and I will accept the consequences of my actions, or lack there of; even if that involves the soiling of my gurney.

Kudos to you, however, I also receive a good nights sleep in knowing that I wasn't unethical, deceiving, or demeaning to my patients. I sleep well in the fact that I did my best for every patient and made no attempt at forming some sort of amusement out of giving fake treatments.

 

[abckidsmom]

Oh thou high and mighty. Thou that knowest all. How exactly dost thou propose I "deal with system abusers". The reason why they're called "system abusers" is because they are incorrigible. And would you treat they guy you just brought in to the ER 30 minutes ago like a "fist time patient"? Oh, now his vague "all over" pain is even more all over and even more vague? Well, I guess I should pretend that I don't know he's used this same line on me every shift I've worked for the last four years and give him some morphine.

Look, all I'm saying is that it makes all the other medics look back when you keep giving malingering patients unnecessary treatments. I get a good nights sleep by knowing that I am smart enough to treat my patients appropriately, even if that means withholding treatment.

Ours is not to label malingerers. Or to be overly sarcastic in this forum. Be nice, OK?

 

[mycrofft]

Parsing.

Despite any explaination to the forum, adminstering a medication not called for, or out of your protocols without exceptional life saving reasons, is anything from grounds to being fired, to poisoning (potentially a felony and certainly civily liable).

Using placebos without order or protocol is likewise, even if they are "inert" or "harmless", especially if done so parenterally or IM/SubQ (assault and battery, unauthorized invasive procedure).

I have heard from a number of patients that they experienced sensations of relaxation, lightheadedness, and/or sleepiness post Toradol injection. A few inmates sought Toradol injections. Most patients reported ansd exhibited signs of pain relief.

PS: in anticipation, the phrase "Oh, Come on!..." is semantically null and guaranteed to rile up a judge or employer.

 

[TheLocalMedic]

Using placebos without order or protocol is likewise, even if they are "inert" or "harmless", especially if done so parenterally or IM/SubQ (assault and battery, unauthorized invasive procedure).

Point taken. But again, the patient wasn't outright lied to, he was never told he was getting a narc or even any kind of medication. He was given an IV and then a saline flush that was pulled from the narc cabinet. Granted, the medic made a big show of transferring the saline from one syringe to another with a stopcock, but never did anyone say it was anything other than a flush ("Nor-malsaline" ). All he said was that hopefully he would feel better. And it calmed the addict down, so mission accomplished.

I think it would be great if our system adopted Toradol though. We are in the process of trying to get Fentanyl right now, but a non-narcotic option for pain relief would be well received.

 

[usalsfyre]

This type of deception is unethical period. Would you like if it was done to someone you care about?

 

[Medic Tim]

The pt should know what you are giving them and why. There also needs to be a legitimate reason for doing so. Misrepresenting what you are giving your pt is unethical and grounds to have your license pulled. If you are going to treat them then do it the way you are supposed to.

Please tell me they never started the iv just to give the saline.

 

[usalsfyre]

I really don't understand the desire to keep defending this practice.

 

[TheLocalMedic]

Again, let me stress very well known system abuser who calls multiple times a day to demand a ride into town and to be given morphine. Each time he is given a full assessment (gotta CYA) and depending on his complaint du jour, is sometimes given an IV as part of the routine care provided, so no, no one is getting poked just for the heck of it. But he is frequently very angry, yelling that he wants morphine. Bear in mind as well that this area staffed with only a few ambulances, so when he calls multiple times a day, often the same crew sees him over and over again. Would you shell out narcs every time you picked this guy up? If someone were to walk up to you and ask, would you just open your narc box and let them have their pick?

And if it was someone I cared about, I would like to think that the crew dealing with them would recognize that the last thing that person needs is someone encouraging their destructive drug seeking behavior. Give them a ride, give them an assessment just like everyone deserves, but please don't give them drugs that aren't warranted.

 

[usalsfyre]

No, I wouldn't "shell out narcs" every time, but I d@mn sure wouldn't perform misrepresent a treatment in a deceptive manner either, which is the crux of the matter.

As for dropping a deuce on the cot? That's why we get paid the big bucks.

 

[TheLocalMedic]

LOL, right, the big bucks.

Well, at this point I guess I don't have much more to add. The saline flush apparently calms him down, so people will probably keep giving it to him, and I can't really argue with that. He's been a frequent flier for years, and will continue to be a regular for years to come, so what can you do? They tell him outright that they aren't giving him morphine, and that's generally where the discussion ends. Occasionally a newbie who hasn't run into him yet will give him some morphine, and he tells us about it the very next time we see him and he openly admits that he "tricked 'em that time". He won't be tricking me though.

 

[RocketMedic]

I personally don't try and deceive my patients.

 

[mycrofft]

So the treatment plan is either an intervention to break a destructive lifestyle, or keep from getting fooled? Not somethings addressed by many EMSA's.

OK, get a standing order from the medical officer either allowing placebos, or a standing order not to give that one person analgesia and truthfully tell the pt.

I almost blew off an admitted faker the one time he was right, and he died during CPR under my hands.

 

[johnrsemt]

Talk to the medical director and the police; get the Doctor to sign off on the person going to jail everytime he calls 911 and the medics clear him. It will stop the patient from calling so often.

I will not lie to a patient and tell them that a NS flush will make them feel better; although I had a patient with a ED inserted heplock, that when I flushed it with NS prior to giving Fentanyl; the patient (who was moaning and yelling in 'pain' stated that he felt much better, and slept for the next 60 miles. And that was just after 5mL of NS. All I did was flush it to make sure it was still patent. He thought he had been given the drug; I never said a word beyond "relax I will give you something that will help the pain"

 

[Veneficus]

I will not lie to a patient and tell them that a NS flush will make them feel better; although I had a patient with a ED inserted heplock, that when I flushed it with NS prior to giving Fentanyl; the patient (who was moaning and yelling in 'pain' stated that he felt much better, and slept for the next 60 miles. And that was just after 5mL of NS. All I did was flush it to make sure it was still patent. He thought he had been given the drug; I never said a word beyond "relax I will give you something that will help the pain"

It is not a lie to say "this might make you feel better"

As you have seen, placebo effect counts.

Really though, I am a big advocate of treating pain, there is no reason not to. There is definately a breakdown in the system when the only option you have is a narcotic.

I once heard somebody say "Never judge, always help" (I forgot who) but it is something that has served me well.

 

[Dwindlin]

I once heard somebody say "Never judge, always help" (I forgot who) but it is something that has served me well.

I agree with the sentiment but frankly giving a known abuser what they want isn't helping anyone.

 

[Veneficus]

I agree with the sentiment but frankly giving a known abuser what they want isn't helping anyone.

I tried to stay away from this topic...

Does a substance abuser lose the right to have their pain treated?

Do we treat pain regardless of the cause or do we make a moral decision on who is worthy and why?

As food for thought,

Anesthesia in surgery allows providers to inflict damage upon the body. (Under the intent that the damage inflicted is more beneficial than not inflicting)

Is it ok to inflict social/psych damage and not offer analgesia?

How many drug abusers will actually undergo reform and become productive members of society?

What drives the ones who do? Do you really think it is lack of access to thier substance?

If it is ok to palliate people with terminal illnesses, what makes it so reprehensible to palliate people with social/psychiatric affliction?

 

[18G]

I tried to stay away from this topic...

Does a substance abuser lose the right to have their pain treated?

Do we treat pain regardless of the cause or do we make a moral decision on who is worthy and why?

As food for thought,

Anesthesia in surgery allows providers to inflict damage upon the body. (Under the intent that the damage inflicted is more beneficial than not inflicting)

Is it ok to inflict social/psych damage and not offer analgesia?

How many drug abusers will actually undergo reform and become productive members of society?

What drives the ones who do? Do you really think it is lack of access to thier substance?

If it is ok to palliate people with terminal illnesses, what makes it so reprehensible to palliate people with social/psychiatric affliction?

Awesome points.

 

[mycrofft]

Do a good exam, treat based on objective exam. Protocols based strictly upon subjective complaint are not only insulting, they can allow you to stray then you will be told your professional judgement is lacking when you overtreat or mistreat based upon complaints.

Know the diagnotic differentials for common complaints, especially those that watershed at lifethreatening versus no biggee. Ask open ended questions as much as you can. DO NOT, even as a rebuke, list for the pt the signs and complaints you look for. And when in doubt, treat safely with continued eval for effect.