Not always so. If your pt is definitely in ths lls ( looks like $hit) category you want a medic. But for 90% of trauma and 40% of medical, waiting for als is just b.s. When you get some time logged feel free to play within your scope
Treat on scene or transport?
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Not always so. If your pt is definitely in ths lls ( looks like $hit) category you want a medic. But for 90% of trauma and 40% of medical, waiting for als is just b.s. When you get some time logged feel free to play within your scope
I agree with not waiting for severe trauma. There was a study done somewhere showing that BLS care actually improved trauma results for severe multisystems trauma because of decreased scene times. I'll see if I can dig it up.
But for medical runs, depending on how far away ALS is, it usually helps to wait a few minutes so ALS can begin treatment--this allows earlier STEMI recognition, among other things. Non-serious trauma could also benefit from pain management by ALS, though this depends on your system.
Depends who you ask. I'm all for it.
Contemplate: To Thoroughly consider. Therefor they will take into account all information and determine if analgesics would be appropriate. Every situation is different, if they are tolerating the pain you shouldn't give them pain killers. (Because of: unknown allergies, pre-existing addictions, waste of medication, unneeded alteration of mental status, the list goes on) Isn't that common sense? Yeah, I'm gonna say you're reading too much into it... or not enough.
Brandon O
Puzzled by facies
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What does it mean to be tolerating pain? The screaming is not too obnoxious?
Tolerating pain. Basically anything less than 7 out of 10 on the FACES scale (faces to weed out habitual drug abusers) is unnecessary use/abuse/waste of narcs. 7 and up use pain killers or NO2.
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You mean the Wong-Baker scale?
You can't put a number on when to treat vs. when to withhold when it comes to pain. It's a case by case basis. I had grandma with obvious deformity to her femur and she told me her pain was a 1/10, laying there cracking jokes and asking if she could have a glass of wine while we worked. I still consciously sedated her because I knew it was going to get worse when we moved her. Turned out she had 3 oblique fractures to her proximal femur...Did I waste my versed and fentanyl because she was only a 1/10?
Just one example.
The pain scale is rated on what the patient has experienced to grade their pain, if you have someone who's had a history of a extremely painful injury their scale is going to be skewed. Just like if you have someone who's lived in a bubble their whole life and the "worst" pain they've ever had is a papercut.
What is everyone's issue with analgesia? It doesn't make your chart any more complicated and in fact probably makes it easier to write rather than justifying why you didn't treat the patient's pain.
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You mean the Wong-Baker scale?
You can't put a number on when to treat vs. when to withhold when it comes to pain. It's a case by case basis. I had grandma with obvious deformity to her femur and she told me her pain was a 1/10, laying there cracking jokes and asking if she could have a glass of wine while we worked. I still consciously sedated her because I knew it was going to get worse when we moved her. Turned out she had 3 oblique fractures to her proximal femur...Did I waste my versed and fentanyl because she was only a 1/10?
Just one example.
The pain scale is rated on what the patient has experienced to grade their pain, if you have someone who's had a history of a extremely painful injury their scale is going to be skewed. Just like if you have someone who's lived in a bubble their whole life and the "worst" pain they've ever had is a papercut.
What is everyone's issue with analgesia? It doesn't make your chart any more complicated and in fact probably makes it easier to write rather than justifying why you didn't treat the patient's pain.
I don't mean it as an end all be all. And as for the Wong baker ( aka faces) it is generally a better system to go by versus what a pt may tell you when in an area with a lot of habitual users. I'm not saying don't ask but take the response with a grain of salt and use your better judgement. Besides once you administer pain killers you need to assume a drug induced change in mental status as well as alteration in the patients view of changes in other pains that may mask the development of a more serious condition (ie: did the pain cause the accident or did the accident cause the pain). I'm also not saying withhold pain killers but having seen medics give painkillers just because the patient is screaming their head off and never noticing the dozens of track marks on the pt.s arms... Use your judgement and remember it's the PTs wellbeing we need to consider, not their comfort.
Is it really that terrible if you don't rigorously screen your patients to see if they're drug seekers before administering pain medication? How much harm does it cause if one or two seekers slip under the radar and receive morphine as opposed to a medic withholding analgesics from patients for fear that they're faking it?
JPINFV
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...and there's a study that shows that Home Boy Life Support (i.e. private vehicle) has increased survival for trauma than BLS.
It's not for fear of harm and I'm not advocating the withholding of narcs, all I'm saying is there is widespread abuse of the use of painkillers, wether its for billing, burnt- out medics just wanting to shut up a pt, or drug abuse. I see the overuse of narcs and I'm just advocating use of judgement. I dare anyone reading this to ask their QAQI officer if the misuse of painkillers would cost them their job/card... Judgement. I would rather air on the side of caution than blindly administer drugs just because it makes things easier. But that's just my opinion
Shishkabob
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There are much better ways to quiet an annoying person than giving them a narcotic.
And I dare you to find a QAQI officer who says giving narcotics to someone in pain would constitute an infraction worthy of losing your job and having the state EMS board revoking your license. (You wont)
I'm a big advocate for pain control, however I also have no qualms witholding them from people I don't deem benefiting from them.
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I'm not saying legit pain shouldn't get pain killers. The addict faking pain should not. And again I see medics give pain killers because the pt WANTS them not because they NEED them. That's the distinction I'm trying to make. And again you want to be careful that the administration of pain killers isn't going to mask additional symptoms or cover the development of new ones. I'm not trying to pick a fight over this I just want people to think rather then blindly dose PTs before absolutely sure it's the right thing to do. And if your only 5 or 10 minutes from the ER is it really worth it IF it deminishes the reliability of the patients bedside interview, and IF it doesn't cause any undue harm to the pt? Again, I'm just advocating airing on the side of caution, that's all.
Wasn't there a study done about (correctly administered and dosed) paid management not really effecting bedside interviews?
I could be very wrong, but I thought I read about this.
And let me see that I'm also not advocating handing out narcotics like candy (not that I can as a basic...I'm limited to Tylenol), but I do think there is a notion in EMS that pain isn't a big deal, which I disagree with.
However, yes, giving pain meds because it upgrades your billing money is bad news.
I could be very wrong, but I thought I read about this.
And let me see that I'm also not advocating handing out narcotics like candy (not that I can as a basic...I'm limited to Tylenol), but I do think there is a notion in EMS that pain isn't a big deal, which I disagree with.
However, yes, giving pain meds because it upgrades your billing money is bad news.
Shishkabob
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I once had a physician none too happy that I gave a narcotic analgesic to "his" abdominal pain patient because it would "screw up" his assessment. I took out a package of Narcan and handed it to him.
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I see what you're getting at but on the other side of it addicts can have pain. Just because they are a drug addict doesn't mean they can't hurt themselves or be in pain.
I never said go around blindly giving narcotics, I agree with you fully about using your judgement. The problem with pain is it's a very subjective thing. Yea sometimes you can walk up to someone and see and injury and say "wow I bet that hurts would you like something for the pain". At the same time I've seen plenty of people who looked like they were in a lot of pain but adamantly refused being in any pain at all.
I don't care if I'm across the street from the hospital. If the patient is in pain you need to treat it. A proper dose of fentanyl isn't going to make the patient impossible to assess, on the contrary it can make the assessment easier because the patient is able to focus on the questions you are asking them rather than focusing on how much pain they are in. Plus sure you may be close to the hospital but who knows how long they are going to sit in an ER room waiting for a doctor to see them, then waiting for the doctor to order analgesia, then waiting for the nurse to pull it from the Pyxis, draw it up and administer it.
I'm big on giving another little dose of fentanyl as we are in the ambulance bay for the exact reason I outlined above. The beautiful thing about fentanyl is it doesn't give the patients the "rush" or "loopy" feeling that morphine does unless you are hellbent on snowing them and even then it's going to take more, in most cases, than 100-200 mcg.
When it comes to our QAQI here you will be called to the table if you consistently are NOT treating patients pain just as fast as you will be if you go around handing out narcs to everyone.
Like I said, I see what you are getting at, I just don't agree with your outlook on it. Is it possible that the medic you highlighted in the post I quoted saw something you didn't? Not knocking you, I don't know you or your education and I say this with all due respect it's very possible the medic had a bit better of an idea what was going on than you did.
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That frankly is absolute crap. Obviously I can't give the pain meds, but I can call for someone that can, and I am not using a cut and dry rule on who gets pain control and who doesn't. Someone's facial expression is one (rather crappy tool) for determining someone's pain level, as is the number they tell us. Furthermore, if I had to pick a number regarding acceptable pain, I think I'd pick two, I came to such conclusion after speaking with an ED doc who stated that it's difficult to get anything productive done with the dosages required to get a patient to zero since they're now likely to be asleep.
If you are relieving someone's pain, it is not an unnecessary use of medication, and it is certainly not abuse or waste. Ever been in a position where you needed such medications? If you have, you'll know that if someone withheld them that you would have been in bad shape. If you haven't, take our word for it.
Being 5 or 10 minutes out from the ED is no excuse either. The patient needs to be moved from their current position which likely exacerbate pain and you have no idea how long it will take for the ED to provide pain control either. Research shows that pain control does not diminish the quality of an H&P and if anything makes it more useful.
I have never seen an overuse of pain control. In this country we have the opposite problem generally, and many members have personal stories of this occurring as well. I cannot stand those that refuse pain medications or a call for ALS because they think the patient is seeking. How do you know that the person is not in pain? You don't, and even if they are seeking, your one does is not changing anything for an addict.
Pain is something to be treated, no matter the situation or your education.
the_negro_puppy
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I think he's reading too much into it as in " you might consider giving some pain relief, as if its a left field option"
Anyone with a fractured femur (read: NOF) will be getting an IV and at least small dose of morphine before I attempt to move them. They may be pain free at rest, but movement is a whole new ballpark including all the bumps in the road on the way to hospital.
Also many oldies I come across don't like to complain- they come from a different generation and some are quite tough old buggers who will put up with severe pain rather than "being a hassle".
I treat pain aggressively and have never "snowed" anyone. In the odd event it happens I have Narcn and a BVM to fix that. I often give drugs as we are pulling into the hospital- time to triage and into a bed can be 15-4 hours
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Brandon O
Puzzled by facies
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As a quick note, the Wong-Baker scale is not supposed to be little illustrations you compare to the patient's presentation (like in Scrubs). It's intended for pediatric patients who aren't great with numbers. They point at the face that corresponds to their own pain. It's still subjective.
I think what you're trying to get at is the fact that certain things we do help reduce mortality (deadness) and long-term morbidity (disease or disability). Other things we do help reduce suffering. Since the former is permanent and the latter is not, we should not compromise the former for the sake of the latter.
That's probably true. But as people have mentioned, it's generally been shown that field analgesia doesn't compromise patient exams. Moreover, it would be an extremely rare situation where a determination was actually being made based on that exam. Generally imaging is going to occur to rule out badness anyway.
I have never worked in, or even heard of, a system where analgesia was OVERused. That's almost unfathomable to me. As a rule, we are amazingly stingy with the good stuff in the field. This is for various reasons, including restrictive protocols, logistical burdens to replenish narcotics, and so on. But mostly, I think it's because of what you described. We don't like being fooled, so we keep an eagle eye out for "seekers."
My attitude: it's better to give drugs to 100 addicts than to let one patient suffer in pain we could have relieved. Unquestionably those addicts are a problem, and their use of the healthcare system is a problem. But we're not the ones who need to solve it. The single bolus of morphine you're giving them is a drop in the bucket compared to their long-term habit. In fact, the amount of suffering you're relieving by giving narcs to an addict is profound; their pain is real. Let their PCP or the doc at the pain clinic worry about fueling a habit. Withholding analgesia from them is like yelling at homeless people who call 911 because they're cold. It makes you feel better, but it's not going to address the larger problem. How about we just help each patient the best we can and let someone else fix healthcare in America?
Pain is really easy to downplay. It doesn't look like anything. But I assure you it's a very big deal to the person in pain. Try it sometime. You may find that the distinction between "wanting" and "needing" pain relief is somewhat fuzzy. Do patients "need" anything? I don't know what that means. Can we help them? You'll have a chance to help a thousand people out of their suffering in this business before you get a chance to save a single life. If you refuse to address those people on the grounds that you're only here for complaints that kill people, you're not going to accomplish much during your shift.
Take a look at this pain protocol (more info here). In brief, if you walk into this ED in pain, they'll give you .1mg/kg of morphine (plus some benedryl for the side effects), period. Then every seven minutes, they'll ask if you'd like some more pain medicine. If you say yes, you get another .05 mg/kg. They repeat this every seven minutes until you say no, or you fall asleep. They don't turn it into an ethical conundrum or try to gauge how much pain is enough. They just fix it.
Given the choice, why not be the candyman? Compared to most complaints we see, do you realize how much we can help these patients?
I think what you're trying to get at is the fact that certain things we do help reduce mortality (deadness) and long-term morbidity (disease or disability). Other things we do help reduce suffering. Since the former is permanent and the latter is not, we should not compromise the former for the sake of the latter.
That's probably true. But as people have mentioned, it's generally been shown that field analgesia doesn't compromise patient exams. Moreover, it would be an extremely rare situation where a determination was actually being made based on that exam. Generally imaging is going to occur to rule out badness anyway.
I have never worked in, or even heard of, a system where analgesia was OVERused. That's almost unfathomable to me. As a rule, we are amazingly stingy with the good stuff in the field. This is for various reasons, including restrictive protocols, logistical burdens to replenish narcotics, and so on. But mostly, I think it's because of what you described. We don't like being fooled, so we keep an eagle eye out for "seekers."
My attitude: it's better to give drugs to 100 addicts than to let one patient suffer in pain we could have relieved. Unquestionably those addicts are a problem, and their use of the healthcare system is a problem. But we're not the ones who need to solve it. The single bolus of morphine you're giving them is a drop in the bucket compared to their long-term habit. In fact, the amount of suffering you're relieving by giving narcs to an addict is profound; their pain is real. Let their PCP or the doc at the pain clinic worry about fueling a habit. Withholding analgesia from them is like yelling at homeless people who call 911 because they're cold. It makes you feel better, but it's not going to address the larger problem. How about we just help each patient the best we can and let someone else fix healthcare in America?
Pain is really easy to downplay. It doesn't look like anything. But I assure you it's a very big deal to the person in pain. Try it sometime. You may find that the distinction between "wanting" and "needing" pain relief is somewhat fuzzy. Do patients "need" anything? I don't know what that means. Can we help them? You'll have a chance to help a thousand people out of their suffering in this business before you get a chance to save a single life. If you refuse to address those people on the grounds that you're only here for complaints that kill people, you're not going to accomplish much during your shift.
Take a look at this pain protocol (more info here). In brief, if you walk into this ED in pain, they'll give you .1mg/kg of morphine (plus some benedryl for the side effects), period. Then every seven minutes, they'll ask if you'd like some more pain medicine. If you say yes, you get another .05 mg/kg. They repeat this every seven minutes until you say no, or you fall asleep. They don't turn it into an ethical conundrum or try to gauge how much pain is enough. They just fix it.
Given the choice, why not be the candyman? Compared to most complaints we see, do you realize how much we can help these patients?