Treatment Question

mycrofft

Still crazy but elsewhere
11,322
48
48
Note to Brown on American Analgesia

I wonder if it is a historic relic. Many times battlefield casualties (the roots of our EMS lore and science) seen first by medics had enough morphine on board to bother the anesthesiologists of the day at the MASH or whatever. Furthermore, some casualties undoubtably arrived obtunded and without adequate documentation to assist triage . This may have led to our reliance on biting on a piece of rawhide or whatever.
Even then, it is arguable that analgesia either helped combat shock, or at least comforted someone in extremis.
 

usafmedic45

Forum Deputy Chief
3,796
5
0
I wonder if it is a historic relic. Many times battlefield casualties (the roots of our EMS lore and science) seen first by medics had enough morphine on board to bother the anesthesiologists of the day at the MASH or whatever. Furthermore, some casualties undoubtably arrived obtunded and without adequate documentation to assist triage . This may have led to our reliance on biting on a piece of rawhide or whatever.
Even then, it is arguable that analgesia either helped combat shock, or at least comforted someone in extremis.

Actually, if you look at the data from WWII (the last major conflict where your standard company aidman was told to dose people willy nilly with morphine) there was a significant rate of overdose among wounded casualties. That's one of the primary reasons it fell out of favor.
 

usafmedic45

Forum Deputy Chief
3,796
5
0
And how many times have we seen someone* announce "That guy's got COPD, fergoshsakes get that O2 off", it is DC'ed, and the pt starts to decompensate? Nice to have some scientific muscle behind decades of observation, excellent.

* New EMT, in the ambulance, after leaving the originating facility where the pt was on O2, in most cases. :sad:[/FONT]

Quite a few times. Usually right before I resort to (choose one or more):
1. Suspending them
2. Firing them
3. Letting our medical director know so he can decide whether to go after their credentials.
 

mycrofft

Still crazy but elsewhere
11,322
48
48
WII morphine syrettes (I digress)

Individual aid kits sometimes included a morphine syrette.
Just found this wild website, "WW2 US Medical Reserach Centre":
http://www.med-dept.com/morphine.php

Brown, we may have found your culprit. Morphine syrettes took 20 to 30 minutes (!!!) to take full effect, longer if the injection was placed in poorly circulating skin.
 

usalsfyre

You have my stapler
4,319
108
63
containing ordinarily ½ Grain of Morphine Tartrate

1/2 grain, if I'm doing my calculations right, seemingly comes out to 30mgs and some change. The majority of paramedics I know would be messing their drawers with that level of dosing :D.
 

MrBrown

Forum Deputy Chief
3,957
23
38
It would appear 1/2 grain is 0.032g or ... 32mg

You know IV anaesthesia fell out of fashion for a while too after the high mortality rate experienced by Trippler Army Hospital during the Pearl Harbour attacks too, why? Because the physiology of shock and need for adequate oxygenation (and hmm, a bit less IV thiopental?) was poorly understood.

And then we got over it ....
 

usafmedic45

Forum Deputy Chief
3,796
5
0
You know IV anaesthesia fell out of fashion for a while too after the high mortality rate experienced by Trippler Army Hospital during the Pearl Harbour attacks too, why? Because the physiology of shock and need for adequate oxygenation (and hmm, a bit less IV thiopental?) was poorly understood.

More likely it was the lack of blood transfusion capability than anything else. Even the ability to store plasma was very new and literally 99.99% of the nation's supply was on a plane bound for Pearl the day of the attack.

There are several good references freely available on the internet from the US Army Medical Corps that discusses the issues pertaining to pre-, intra- and post-operative resuscitation during WWII. Most of them pin the blame on the failure to recognize that it's not just volume but circulating red cell volumes that you have to replace in a trauma patient (in addition to stopping any further blood loss). Gee...this all sounds vaguely familiar....
 
Last edited by a moderator:

J. Burdett

Forum Crew Member
38
0
6
Sounds like a handful!

My initial treatment probably would've consisted of Xopenex via neb at 6lpm, 18g IV w/ 250ml bolus, and Trendelenburg positioning if the pt would tolerate it.

I've witnessed Trendelenburg increase BP many, many times. It's not a myth in my book. What was the pt's position upon arrival and what position did you transport her in? If she was supine and you transported in semi-fowlers the drop in BP would be expected given the suspected hypovolemia.

Also, I would have to say MS would be a poor choice for this pt due to it's histamine release which could exacerbate her hypotension and bronchospasm, depression of the vasomotor center in the medulla could also exacerbate her hypotension, and stimulation of the CTZ could exacerbate her vomiting. No bueno.

That's just me though!



I have a 77y/o Female. We were called for weakness, difficulty breathing, abd pain. She has been feeling weak and has had the abd pain for approx. 1 week. She does not remember when her last bowel movement was and has been vomiting for the past couple of days. She also has COPD. Her lung sounds there was some wheezes present. Pt has not ate anything in the past couple of day either. Pt is 130 Sinus Tach. Pt had labored breathing at 22x min. Pulse OX 83% via a NC at 4lpm. 12 lead was negative and a blood glucose was 90 mg/dL. PT was AO X3 for the whole transport. Also pt rated her pain a 10/10 very tender upon palpation. Her first pressure was 97/79. I have an approx. 7 Min transport time. I started a breathing treatment, IV (18GA). Upon my arrival to the ED her pressure had fallen to 74/42. I did not place her in a trendlenbug position due to her COPD. Her next pressure while in the ED was 62/44. The ER nurse decided to yell at me that her breathing was not an issue and I should of for went the treatment and placed in in trendlenburg position. My belief was that there is no clinical proof that the trendlenburg position was effective and I wanted to correct her breathing problem before she went in to respiratory arrest. Also her pressures didn't start dropping until we were already in the ED. I am just wondering what should or could I of done different.
 

systemet

Forum Asst. Chief
882
12
18
What are you treating?

I recognise and respect that you're a physician, and I think I understand the point that you're making -- but given that it's essentially impossible to rule out life-threatening causes of abdominal hemorrhage in the prehospital environment, wouldn't it be more humane to administer a dose of fentanyl here?

If this is an aortic aneurysm, is it likely that the fentanyl is going to be the push on the see-saw that results in clinical misadventure? (This is an honest question, I'm happy to be corrected here if I'm in error).

And if we're seeing a bowel obstruction (which doesn't seem to be clear here), is a small amount of narcotic with a short t1/2 going to push a medical case towards surgical management? And if so, is this risk worth leaving the patient in acute pain?

I accept that once the patient decompensates pain management is less of a priority, but with an initial pressure of 97/systolic, it seems like fentanyl, or a small dose of morphine might be reasonable. Or not?

With respect.
 

MrBrown

Forum Deputy Chief
3,957
23
38
I accept that once the patient decompensates pain management is less of a priority, but with an initial pressure of 97/systolic, it seems like fentanyl, or a small dose of morphine might be reasonable. Or not?.

Brown does not think it is unreasonable, perhaps what is unreasonable is the mentality of ambo's who feel uneasy about such situations because they push the bounds of their limited education and critical thinking so shy away from such decisions.

Again, this is not being a renegade cowboy free to practice wanton rogue medicine ... it is about critically analysing the situation before you and responding appropriately based upon proportional clinical risk vs benefit.

Lets put this another way: Do you give Nana who has a history of two infarcts adrenaline for her life threatening asthma or not?
 

RocketMedic

Californian, Lost in Texas
4,997
1,461
113
With a 7-minute transport time, I personally would not manage her pain. Pressure dropping that much over a 7-minute transport, nonspecific abdominal pain, advanced age, COPD, near-certain polypharmacy, and a lack of food x 4 days, to me, is a great sign of a life-threatening abdominal problem, probably a bleed. I have no objections to running a small fluid challenge, but for such a short transport, I wouldn't go for the narcs.

If transport time was longer AND I had a positive response from Trendelenberg and the fluid challenge AND I felt that her respirations were adequate, THEN I would probably give fentanyl if available. Morphine if not, in small doses- say 1mg initial with 0.5mg for effect.
 

MrBrown

Forum Deputy Chief
3,957
23
38
With a 7-minute transport time, I personally would not manage her pain.

Would you manage pain for somebody with a shattered femur or rupturing ovarian cysts? What about somebody who has burn pain or somebody who has appendicitis?

What little faith Brown has in American Paramedics is not going to get bigger any time soon.
 

RocketMedic

Californian, Lost in Texas
4,997
1,461
113
Brown, considering that in all of those cases, you have posed patients with relatively clear-cut complaints. The OP involved an elderly woman with nonspecific abdominal pain, COPD, unknown pharmacy, and unknown other history WITH A SHORT TRANSPORT TIME! This patient was not in a critical life-threatening amount of pain, but her V/S were enough to alarm not just a paramedic, but the receiving team and the MD as well. This patient is not the one we want to start depressing with narcotics.

What faith I have in New Zealand's EMS is not shaken, but I'd recommend you refrain from insults. I'm sure there's a lot that we could pick apart about NZ as well.
 

RocketMedic

Californian, Lost in Texas
4,997
1,461
113
Would you manage pain for somebody with a shattered femur or rupturing ovarian cysts? What about somebody who has burn pain or somebody who has appendicitis?

What little faith Brown has in American Paramedics is not going to get bigger any time soon.

Yes, by splinting and then chemically, as needed, absent contraindications.
Ruptured ovarian cysts- depends, but probably (absent any contraindications).
Burns- That's pretty obvious.
Appendicitis- Yes.
 

STXmedic

Forum Burnout
Premium Member
5,018
1,356
113
Transport time and time to treatment are completely different.
7min transport time + 2min park, call out, unload, and get in the ER + 3min for you to get a room assignment + 5min until a nurse comes in for report + 10min until the doctor finally shows up and orders anything + another 10min for the nurse to get the Rx, chat with employees on the way back, and finally administer the pain management = the patient unnecessarily being in pain for far too long.
If you have pain management as an option, transport times should not be one of the issues considered when deciding on whether or not to use them! I've given fentanyl to a patient when we were <2 blocks from the hospital. There is no need for a patient to suffer longer if we can alleviate that suffering.
 

CANMAN

Forum Asst. Chief
805
425
63
Brown, considering that in all of those cases, you have posed patients with relatively clear-cut complaints. The OP involved an elderly woman with nonspecific abdominal pain, COPD, unknown pharmacy, and unknown other history WITH A SHORT TRANSPORT TIME! This patient was not in a critical life-threatening amount of pain, but her V/S were enough to alarm not just a paramedic, but the receiving team and the MD as well. This patient is not the one we want to start depressing with narcotics.

What faith I have in New Zealand's EMS is not shaken, but I'd recommend you refrain from insults. I'm sure there's a lot that we could pick apart about NZ as well.

I am sorry but I gotta back up RocketMedic here as well. If my transport time was 7 minutes long then I am sorry but pain management is certainly not the top thing on my list in this case. Not to mention the fact her pressure dropped upon present to the ED and not giving narcs saved the extra explaination to an already PITA RN about you gave her XXX mg of Morphine and now her pressure is in the crapper.

If some people on this forum can break out the narcs, draw up, and administer morphine, fentanyl, etc in a matter of a couple blocks then you are certainly a better medic then I. It takes a solid 2 minutes for me to access safe, open second seal, remove med, draw up med, check med, then give med.... I get the whole " no one should have to suffer from pain " trip but honestly NO ONE dies from pain either.... Think about how many people with abdominal pain present to the ED themselves and sit in the waiting room at large hospital for hours, I know in my area, inner city, it isn't unheard of to wait 8 hours.
 

usalsfyre

You have my stapler
4,319
108
63
I am sorry but I gotta back up RocketMedic here as well. If my transport time was 7 minutes long then I am sorry but pain management is certainly not the top thing on my list in this case.
As I stated before I've got some reservations about opiates in this case...but transport time is not (nor should it ever be) one of the factors.

Not to mention the fact her pressure dropped upon present to the ED and not giving narcs saved the extra explaination to an already PITA RN about you gave her XXX mg of Morphine and now her pressure is in the crapper.
This is what's known as "losing patient focus". Not having to explain something that's needed to the receiving staff is one of the poorest excuses I've ever heard. I've been known to tell receiving nurses (and for that matter physicans) who got crappy the number where they could reach my medical director. He's never gotten a call to my knowledge.

If some people on this forum can break out the narcs, draw up, and administer morphine, fentanyl, etc in a matter of a couple blocks then you are certainly a better medic then I. It takes a solid 2 minutes for me to access safe, open second seal, remove med, draw up med, check med, then give med....
I'll bet I can acomplish this in around a minute, and I've pushed narcs as we were backing in the ED bay before.

I get the whole " no one should have to suffer from pain " trip but honestly NO ONE dies from pain either....
I was waiting for this. In the words of Rogue Medic...prove it.

Think about how many people with abdominal pain present to the ED themselves and sit in the waiting room at large hospital for hours, I know in my area, inner city, it isn't unheard of to wait 8 hours.
Different situation. None of those folks are waiting 8 hours to get triaged.
 

Melclin

Forum Deputy Chief
1,796
4
0
Too many things I wanna say.

I wish I'd have thrown my hat into the ring earlier.

Maybe it's not where your from but out here you need a systolic of atleast 100. And since her Second BP was 72/(who cares that is too low anyways) and she is fluid depleted anyways not to mention that MS has vasodilatory effects I would never even think of giving this to her. But you cowboys out In NZ are doin it different. She has a fluid problem fix that first. Not to mention do I really wanna slow down her labored breathing w/ wheezes? Come on I know you guys might play MDs on TV but let's get back to the basics....low BP fix it.
But Im just a CA medic what do I know right?

Not that I think it applies to this case, but I've found that mildly hypotensive pts often come good with a bit of morphine rather than the other way around.

Hell, we put 45mg of morphine into a bloke the other night and it didn't touch his blood pressure.

I'm having a bit of trouble picturing this pt, but if her COPD is really hitting her hard, I'd be more concerned about morphine and that. But it would just mean I went gently.

Still, my partner says I could come across a runny nose and I'd still have a line in, a litre of fluid up and 10 of morph in by the time we got to the truck :p

The initial BP was 97/79 that is entirely an appropriate BP for a small dose of morphine, it's not an appropriate BP for GTN


A respiratory rate of 22/min is not really laboured although Brown conceeds somebody with a very long expiratory phase (such as a wheezy asthmatic) might also be considered laboured breathing.

If morphine and other opiod analgesics have such a negative respiratory effect then maybe they should not be given to anybody?

Do you know how many patients Brown has seen firsthand, heard about second or thirdhand that have suffered any sort of respiratory problems from having morphine administered? None.

I had this condundrum the other day, male mid 30's I think, super serious asthma hx, sounded like he'd fractured a rib earlier in the night and then his asthma kicked into gear. The current attack wasn't too bad, but it also wasn't responsive to salbutamol, atrovent and prednisolone. 10/10 chest pain. So I'm thinking gently gently with the morph. Gave him 5mg in the end (ended up sticking the penthrane through the hole in the neb mask which worked a treat incidentally). Didn't touch his resps. I was talking to a CSO about it later and he reckoned as long as I stuck with small increments and kept a good eye on it, I should have just kept going until his pain was under control.

He wasn't worried about the resp depression at all and he's one smart cookie.

Ok so this is my second time typing this cause the long version was reloaded by my ipad before I sent it so it got erased any who. Short hand version, labored breathing was stated by the OP so lets take his word for it, a BP of 97/79 and a second BP of 74/42 and falling isn't concerning to you? I could see pain management if I was a hospice nurse for this pt. As the OP stated she was a ST @ 130 so not really a pump problem. Could we do anything for a bleed? nope. Can I do something to help with her falling BP? sure can, is it the best solution? nope but its better than nothing in the pre-hospital setting. Im not gunna sit around and play Doogie Howser on this pt, its a Fluid challenge,O2, and diesel. The argument here is would MS really benefit this pt? Plain and simple no, would it do more harm then good? guess well never know. There are to many factors we dont know about this pt, and there are a handful of ways this call could have been run. You've got your way I have mine in the end this pt needs one thing... a Doctor. So i guess we could agree to disagree.

Why does a sinus tach at 130 not mean a "pump problem" to you? Pain relief is important in many ways aside from it being humane. If we didn't use analgesics we'd just about never open the drug bag, its a big part of our job.

I can say with complete confidence that we are better at pain management in ambulance than most hospitals. If a pts pain wasn't managed well in hospital, I wouldn't take that to mean it didn't need to be managed.

The plummeting pressure with abd pain says "hemorrhage" to me. A SMALL challenge I might agree with...but I without seeing the patient I can't say.

Like I said before I'm even a little dubious on analgesia, simply because strong sympathetic drive is the only thing keeping these folks alive. The anesthetic technique often described for the patient in severe hemorrhagic shock is "succinylcholine and an apology". However this has nothing to do with B/P or the specific properties of any opiate.

This doesn't scream haemorrhage to me, at least initially. It sounds more like one of the many poorly cared for oldies who are miscellaneous crook and a bit dry. I'm having a hard time picturing this pt from the narrative and the second pressure is certainly cause for concern.

Sux and an apology is considered to be inhumane by a lot of people round these parts. Even very sick pts with generally still get some level of sedation/analgesia for intubation.

Yes, by splinting and then chemically, as needed, absent contraindications.
Ruptured ovarian cysts- depends, but probably (absent any contraindications).
Burns- That's pretty obvious.
Appendicitis- Yes.

You'd splint a femur before any analgesia? :unsure:
 

CANMAN

Forum Asst. Chief
805
425
63
Well somehow my six paragraph defense post didn't post and in turn got deleted and I don't have the energy or care to really type it all again. I just find this forum amusing in the fact that certain people like to dissect peoples entire post. In the OP 83% sats and a borderline pressure without knowing a baseline doesn't scream "get the narcs to me", I am sorry. If you wanna spend 10 minutes on scene to get history, vitals, O2 on board, 3 lead, line, 12 lead, consult, etc and then take you 7 minutes to give meds then great. Me personally I like to work on the way, if anyone on here can do all the above in 7 minutes and give pain meds then great. Time does play a role in certain interventions and if I don't have some basic stuff done then I am not jumping to give pain meds. I am not cold hearted or unsympathetic. If you can draw up, and administer pain meds in under a minute congrats I am excited for you and you deserve a merit badge.

You can ask 20 medics, RN's, or MD's about the same situation, call, patient, whatever and you will most likely get a good amount of different answers. Every provider does some stuff different. On this forum we all come from different backgrounds, skill levels, knowledge base, experience, states, protocols, stengths, weaknesses, you get my drift. Does this mean our patient's are getting a lesser quality of care because we are different. In my short time on the forum there is alot of good info and experienced people on here, but there are also ALOT of egos. Anyone can keyboard quaterback a situation
 
Top