Hemostatic
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Would I be correct in thinking that Toradol is contra-indicated for unknown/suspected TBI? Specifically referring to blast/explosion victims with no other life threatening injuries.
Toradol
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I know of at least a dozen friends that have been given Toradol for kidney stones and it didnt do anything for the pain.
It doesnt seem to be the wonder drug it's been made out to be.
DrankTheKoolaid
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Thas unfortunate as I have seen it work wonders with these patients when used in conjunction with Reglan
Hemostatic
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After re-reading this, I realized I did not do a very good job of wording my question (and I can't figure out how to edit my post), so let me try again.
Would I be correct in thinking that Toradol is contra-indicated for pain management of non-life threatening injuries if the patient has a suspected TBI?
Again referring to blast/explosion victims with no other life threatening injuries.
mycrofft
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NIH article about Toradol
http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id=9090
It IS considered a NSAID, a COX-2 inhibitor, not for use for over five days, active metabolites produced hepatically an a side effect is renal failure (it is excreted renally).
Note: may decrease efficiency of uterine contractions in childbirth (not indicated for childbirth); maybe a smilar action makes ureteral contraction less pronounced, thus helping ith analgesia of liths?
No mention I saw of the relaxation or sedation I have seen or heard reported by pts.
http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id=9090
It IS considered a NSAID, a COX-2 inhibitor, not for use for over five days, active metabolites produced hepatically an a side effect is renal failure (it is excreted renally).
Note: may decrease efficiency of uterine contractions in childbirth (not indicated for childbirth); maybe a smilar action makes ureteral contraction less pronounced, thus helping ith analgesia of liths?
No mention I saw of the relaxation or sedation I have seen or heard reported by pts.
Fortunately it doesn't always
Anyway, stopping a muscle spasm will certainly make things better.
Apparently there was once a study and it has been passed down like gospel that NSAIDs work equal or better narcotics on ortho pain, including fractures.
*note* Not always the best idea to take aspirin for the worst headache of your life
mycrofft
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Make that "LAST" headache of your life.
I've taken the PO form for migraines. It's fantastic.
Do what you do for your dog: rub their nose in it.
Do you think it works better prior to full onset or does it work equally for you even after you have reached "as bad as it gets'?
I don't get auras or much warning. I get sudden onset, and within half an hour, it's as bad as it gets. Usually, ASA/APAP/caffeine helps, so I don't use it much (usually less than half a dozen times a year). But, I've tried it both ways, and it seems to work best when the headache is worst.
ER Felodipine is a lifesaver. I was started on it for HTN and noticed a dramatic decrease in frequency and severity of headaches. But it's expensive without insurance. $10 a month under my current plan.
My PMD is actually on the fence about migraine vs. cluster. They seem to be "migranous in quality" (his words) but cluster like in pattern. I can go months without one. Last year, I had an entire month where I had one EVERY EFFING DAY. (Actually, I think it was all the same, month long headache.)
I think some people may be blurring the line of substance abuser vs. system abuser. They're not the same thing. (You've hit the nail on the head in your post.)
Just this week, I had a heroin abuser from the local shelter. IV track marks, abcess growing on his AC. Walked (limped) up to the local firehouse asking for an ambulance. Said he gets kidney stones, and had a sudden onset of right flank pain. He was a little pale and diaphoretic, and wincing with walking. I tapped his flank, and had to catch him, because his knees buckled. He wins. Got 10 mg of IV morphine. And he was honest: said it didn't remove the pain, but made it more bearable and him more comfortable. He also helped his situation by being polite and pointing out his good veins.
Contrast that with the system abuser who is discharged from the ED and walks to the pay phone to call 911. He's banned from one ED by a court order b/c he's assaulted their staff. He racks up about 80-100 visits a month to 2 hospitals. He's abusive, he's obnoxious, and he does nothing but give our crews a hard time. He demands narcotics by name (although he never gets them). He's trying to get high. He's the epitome of what's wrong in our system.
I work in an urban system where his type is not that uncommon. I call people out for being system abusers all the time. And I consistantly give out a LOT of controlled substances. I'm usually #1 or #2 for the company (for close to a hundred paramedics), and one year I was 70% of the controlled substance administrations company wide.
So I think I do just fine telling the difference.
I did this on purpose, I wanted to get people to think philosophically and recognize that a paramedic is not the arbitrator or enforcer of the morals of part of society.
While I think that most providers actually want to help people, it is important to consider what actually "helps" people in different social and economic classes and the limits of the help medicine can provide.
epipusher
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My post was extremely sarcastic. I believe it is not our job, duty, obligation, or whatever word you think fits best, to judge whether someone is an addict or an abuser or a frequent flier. It is my job to treat the patient, not judge them. If my patient has pain, any kind of pain, they get pain meds.
I am also curious as to what my fellow medics are writing in their run reports regarding why they chose not to treat their patient's complaining of pain. What is being written, if anything, to justify withholding pain medication for someone complaining of pain. Thank you for your time.
As always, this is my opinion.
Edit: Another question to those withholding pain meds because they are an addict. If someone has been addicted to smoking for decades and is now experiencing some sort of respiratory distress, are you withholding oxygen, albuterol or whatever med would help them? Or do you berate them on how they are a detriment to themselves and society due to them making the choice to be a smoker?
I am also curious as to what my fellow medics are writing in their run reports regarding why they chose not to treat their patient's complaining of pain. What is being written, if anything, to justify withholding pain medication for someone complaining of pain. Thank you for your time.
As always, this is my opinion.
Edit: Another question to those withholding pain meds because they are an addict. If someone has been addicted to smoking for decades and is now experiencing some sort of respiratory distress, are you withholding oxygen, albuterol or whatever med would help them? Or do you berate them on how they are a detriment to themselves and society due to them making the choice to be a smoker?
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Aidey
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Depends on their pain level, presentation and history. For example, allergies are listed twice in our reports, and if they have a fent allergy I honestly won't bother explaining why I didn't give them fentanyl since it should be pretty obvious. Same thing if their vitals or presentation are outside the protocol for giving fent. For example, no fent in headache pts with cva symptoms.
For the 10/10 leg pain that walked down 3 flights of stairs to meet us the report will include that info along with something like "pt presented in no acute distress". I feel it is better to include objective info about the pts actions/behavior than just give a subjective opinion. And the level of pt distress is something that makes it into the vast majority of my reports, so I don't really see it as a negative judgemental thing.
For the more inbetween cases it depends. I've had pts flat out refuse pain meds or refuse to be stuck with a needle, so that is what I put.
Frankly, most of my pts who aren't in the aforementioned categories get fentanyl when indicated, so I'm not often documenting why I didn't give it.
For the 10/10 leg pain that walked down 3 flights of stairs to meet us the report will include that info along with something like "pt presented in no acute distress". I feel it is better to include objective info about the pts actions/behavior than just give a subjective opinion. And the level of pt distress is something that makes it into the vast majority of my reports, so I don't really see it as a negative judgemental thing.
For the more inbetween cases it depends. I've had pts flat out refuse pain meds or refuse to be stuck with a needle, so that is what I put.
Frankly, most of my pts who aren't in the aforementioned categories get fentanyl when indicated, so I'm not often documenting why I didn't give it.
I would just offer a word about this when dealing with certain cultures or some older patients.
Some need permission to complain of pain and some will try "to tough out" rather grevious pain.
While I am not doubting your abilities or assessments, it takes a very astute eye to observe they are actually in more distress than they show or report.
I once saw a renal failure patient who had a death grip on the hand rails of her bed, who was from a culture I know are extraordinarily embarassed by pain, and with the most stoic look I ever saw, she explained to the PA her pain was 0/10. (who felt that was enough to withold pain meds)
Later that night we heard her in her room begging god to let her die the pain was so bad.
When I asked her why she didn't want pain meds earlier, she replied, "those are for addicts who cannot cope with life."
Long and short, she ended up with a respectable dose of dilauded, and was extremely appreciative.
Aidey
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I look at 4 main things. How they react while being moved, what their hands are doing, the muscles around the eyes and mouth and how they respond to questions. Short and curt vs long and rambling.
I also like to use the roads as a way to give people an 'out' and not feel like a wuss. "ok sir, i know you said your pain wasn't that bad but you've driven on the roads around here and you know how bad they are. The roads are even worse in the back of the ambulance, especially around St. Acme hospital. I can give you some pain medication now and that should make up for the ambulance and the roads. "
Works pretty well honestly. I've also asked the more "americanized" children of pts if the pt would tell me if they are in pain, and then go from there.
I also like to use the roads as a way to give people an 'out' and not feel like a wuss. "ok sir, i know you said your pain wasn't that bad but you've driven on the roads around here and you know how bad they are. The roads are even worse in the back of the ambulance, especially around St. Acme hospital. I can give you some pain medication now and that should make up for the ambulance and the roads. "
Works pretty well honestly. I've also asked the more "americanized" children of pts if the pt would tell me if they are in pain, and then go from there.
You guys have got to be kidding me. If a patient has ANY kind of pain, they get pain meds? Good lord, we must work in vastly different systems.
So if I call 911 and tell you I stubbed my toe and it's "10/10", I'm getting a narcotic? That's like swatting a fly with a buick.
I'm a paramedic: an experienced, educated medical provider. I use my JUDGEMENT every day on the job, and it includes when someone needs morphine (morphine and midazolam are the only controlled substances we carry). My protocols are just a guideline; they say that in the opening remarks. We finally got morphine standing order for whatever we deem necessary. No more calling for orders, unless we want to exceed 10 mg. (0.1 mg/kg for peds X2.)
Know what? I'm giving more morphine and versed than ever! Now I don't have to call the hospital, wait for the nurse to get a physician, and explain the whole story, and have someone say "Gee, 5 mg is a lot. Why don't you start with 2 and call me if you need more." Did I mention my patient is 200 kg?!? Yes, mam, that's over 400 lbs. Nope. 2 mg, call for more. By that time, I'm there.
The notion that we have to give narcotics to everyone who says they're in pain is just ridiculous. I mean, why not just set up machines at the store like a pop machine, drop in $20, put your rear end up and get your injection of vitamin D. That's all many of these people want. WE are the medical provider. Oftentimes, the patient doesn't know what's best for them.
I still give out a lot of medication. A LOT. More than most all of my co-workders. I also call a lot of bull$hit. Your chronic backpain isn't getting morphine.
I think only having narcotics to treat pain is ridiculous. Even chronic back pain should be treated. "Suck it up" and "you can wait" doesn't seem like a treatment plan to me.
Perhaps not by a narcotic, but if you have nothing else, it seems a bit inhumane to just watch the person suffer. Just my opinion.
I think medical direction that only permits the use of narcotics might be a bit lacking.