Treatment Question

[usafmedic45]

Brown is not trying to pick on specific people but the idea that such notions exist and are actively defended by our international colleagues is a bit frightening

Welcome to the unfortunate idea that everyone's opinion matters even the dumbest idiot in room. As Winston Churchill said, "The best argument against democracy is a five minute conversation with the average voter".

 

[jwk]

But assuring the patient is free of pain and not made to hurt more is too. It's not skipping anything. It simply is shuffling the order to place comfort over checklist medicine.

Shuffling the order is still checklist medicine. Of course you're skipping something. If you have no clue WHY you're treating pain, other than the fact that the patient has pain, then your priorities are off.

 

[usafmedic45]

If you have no clue WHY you're treating pain, other than the fact that the patient has pain, then your priorities are off.

Seriously? You've been around this forum long enough (more than a week) to know that analgesic administration just because we can is not what I am suggesting nor does it take more than a few seconds for anyone but a truly troglodytic moron who habitually drools uncontrollably (and we have more than a few of those in our ranks) to look at someone holding an arm or leg that is bent somewhere it's not supposed to bend and recognize the "clue" why they need to have their pain managed. The one thing that patients will remember above all other- regardless of everything we do for them- is whether we make them stop hurting. Manipulating a fractured extremity without adequate analgesia is painful and unless you have significant extenuating circumstances (fire, shock, need to get to cover due to gunfire, etc) it should be delayed at most a couple of minutes to allow pain control to be initiated. If nothing else, nitrous oxide is WONDERFUL for this. Now if only we didn't have the problem of crews huffing it for their own amusement....

 

[Melclin]

Shuffling the order is still checklist medicine. Of course you're skipping something. If you have no clue WHY you're treating pain, other than the fact that the patient has pain, then your priorities are off.

We know WHY we're treating pain. The why is obvious. Its hurts. Not to mention the host of long and short term, physiological and psychological issues that go with pain. You mean no clue what the CAUSE of the pain is right?

I still don't agree with this at all. Treating pain is easy and fast and there is no guarantee we can figure out what the cause of the pain is. The same can be said of the ED. If they can't figure out whats causing a pt's pain, should they wait until admission for pain relief?

 

[RocketMedic]

No, but by the same token, we need not make our reflexive reaction to deformities a morphine dose. I have nothing against pain management, but I've always learned that it's better to manage pain after an assessment and basic packaging have been completed, at least. Immediately reaching for narcotics before we assess a patient well is bad medicine.

On the topic of the original post, I feel that the conservative approach is the most appropriate. She's been in pain for four days and she's only now dropping her pressure, which to me means that she's decompensating for something. COPD and age contribute to my decision to withhold fluids and narcotics- if she's going to crash as a result of my pain management, I'd rather her crash a few minutes down the road @ the ER as opposed to at the beginning of my transport.

 

[RocketMedic]

We know WHY we're treating pain. The why is obvious. Its hurts. Not to mention the host of long and short term, physiological and psychological issues that go with pain. You mean no clue what the CAUSE of the pain is right?

I still don't agree with this at all. Treating pain is easy and fast and there is no guarantee we can figure out what the cause of the pain is. The same can be said of the ED. If they can't figure out whats causing a pt's pain, should they wait until admission for pain relief?

I'm not arguing that it's not easy, but in some cases (the OP), I feel that the negatives of MS especially in this case outweigh the benefits to the patient (less pain). Absent the BP drop, I would have considered the morphine, but with a 20-point systolic drop in only a few minutes, I would be very, very worried for the possibility of a bleed or other hemorrhagic problem.

Pain should be chemically managed in some cases. In others, I really think that we have other top-priority concerns.

 

[NomadicMedic]

I think this is one of those subjects that is a no win. You're either a "package then pain manage" or a "pain manage, then package" medic.

In cases where a patient is in obvious traumatic distress, an open distal tib/fib fx I recently saw comes to mind, I chose to start my pain management sooner than later. I'll start a line and get morphine on board before I try to package that injury.

I know I'm still a newbie baby medic, but it's important to keep in mind that patients don't remember what you did, they remember how you made them feel.

Obviously this is off in a tangent from the original post, but everyone is harping on the 7 minute transport. 7 minutes is a long time when you're in agony. I think I'd spend an extra minute or three on scene to make my patient comfortable before the ride to the ED. But, that's just how I practice.



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[Handsome Robb]

it's important to keep in mind that patients don't remember what you did, they remember how you made them feel.

This.

There is no one size fits all protocol or guide to treating a patient. If your afraid the vasodilation properties of morphine in a hemodynamically unstable patient such as the one in this scenario, use fentanyl as someone else has already said.

I still am a student, but I don't understand why you couldn't use an analgesic that doesn't have an effect on BP to treat this patient. If it is unavailable then so be it, but if it is, help grandma out, a bumpy ride in the back of the box is only going to exacerbate her pain.

 

[usalsfyre]

This.

There is no one size fits all protocol or guide to treating a patient. If your afraid the vasodilation properties of morphine in a hemodynamically unstable patient such as the one in this scenario, use fentanyl as someone else has already said.

I still am a student, but I don't understand why you couldn't use an analgesic that doesn't have an effect on BP to treat this patient. If it is unavailable then so be it, but if it is, help grandma out, a bumpy ride in the back of the box is only going to exacerbate her pain.

The reality is a lot of places only have homeopathic doses of morphine available for pain management.

 

[usalsfyre]

No, but by the same token, we need not make our reflexive reaction to deformities a morphine dose. I have nothing against pain management, but I've always learned that it's better to manage pain after an assessment and basic packaging have been completed, at least. Immediately reaching for narcotics before we assess a patient well is bad medicine.

Who's saying pain management before assessment? However, pain management prior to manipulating a painful fracture (packaging) in the stable patient IS good medicine.

You won't find a reduction in the ED being done without conscious sedation. It's really not too much trouble to get something on board prior to moving things around.

 

[systemet]

Shuffling the order is still checklist medicine. Of course you're skipping something. If you have no clue WHY you're treating pain, other than the fact that the patient has pain, then your priorities are off.

I understand the point you're making here, and want to repeat that I respect your level of education and training.

But, if we consider the initial scenario, i.e. a patient with undifferentiated abdominal pain -- don't we have to accept at some point that we're not going necessarily going to be able to identify the underlying pathology in an ambulance?

We have minimal (1-3 years) training, (generally) no diagnostic imaging, and often encounter patients who lack a previous pertinent diagnosis. And we're dealing with people who (generally) are excited from just calling 911, and are often poor historians even after calming down a little in the ED.

At some point, doesn't the ethical and appropriate action become recognising the limitations of our training and equipment, and trying to relieve the patient's discomfort? An action which, in of itself, may aid in further physical examination or history?

I'm not suggesting we should be pushing morphine in unstable hypotensive patients -- just that I think it's generally appropriate to treat patients with undifferentiated abdominal pain with analgesia.

 

[usafmedic45]

I feel that the negatives of MS especially in this case outweigh the benefits to the patient (less pain). Absent the BP drop, I would have considered the morphine, but with a 20-point systolic drop in only a few minutes, I would be very, very worried for the possibility of a bleed or other hemorrhagic problem.

Then you get it into your protocols to chase the morphine with 25 or 50mg of diphenhydramine which negates the BP drop which is largely due to the histamine release associated with morphine, in addition to potentiating the desired effects of the narcotic.

....or you revert to using nitrous which does not have a pronounced hypotensive effect whatsoever.

 

[jwk]

I understand the point you're making here, and want to repeat that I respect your level of education and training.

But, if we consider the initial scenario, i.e. a patient with undifferentiated abdominal pain -- don't we have to accept at some point that we're not going necessarily going to be able to identify the underlying pathology in an ambulance?

We have minimal (1-3 years) training, (generally) no diagnostic imaging, and often encounter patients who lack a previous pertinent diagnosis. And we're dealing with people who (generally) are excited from just calling 911, and are often poor historians even after calming down a little in the ED.

At some point, doesn't the ethical and appropriate action become recognising the limitations of our training and equipment, and trying to relieve the patient's discomfort? An action which, in of itself, may aid in further physical examination or history?

I'm not suggesting we should be pushing morphine in unstable hypotensive patients -- just that I think it's generally appropriate to treat patients with undifferentiated abdominal pain with analgesia.

Believe me - I get everything that y'all are saying. However...

I'm taking much of this in the context of the OP's case - abdominal pain of unknown etiology in a sick patient with a 7 minute transport time. In this particular case there is little if anything to be gained by managing this patient in the field. Regardless if it's my guess of bowel obstruction or whether it's a leaking aneurysm or SMA infarct - there just isn't much you can do outside the hospital. Now, if I'm out in the country with an hour transport time, I might consider other options, including judicious use of MS for pain. But with a short transport time and a far from certain diagnosis, I'm just not that hot on field management. If you're doing all these things while transporting, that's fine - although my guess is the OP has done several things (12 lead, blood sugar, IV, etc.) all while at the patient's residence. Again - for this particular case - O2, IV, transport would seem to be reasonable. I'll even go for a little morphine.

 

[jwk]

even if it some methoxyflurane .

Ah, this of course caught my eye as I was reviewing this thread.

Is there anywhere in the world this is used besides Australia? Use of MOF in anesthesia was abandoned 20+ years ago, at least in the US, and it's probably been 25 years since I've used it personally. I don't think it's even commercially available in the US in any form nowadays.

 

[Trevor]

multiple studies have shown that people are more letigious if they are "unhappy". What almost always makes people unhappy???? Lack of pain management!!!! This is one reason JACHO is SO stuck on pain management... Now, Im not saying use this as a guide for treatment of patients, but i am saying think about it... If Im in pain, for the love of everything Holy, GIVE ME PAIN MEDS!!!!! I dont care whats causing the pain! This mentality of being afraid to or it being an "inconvience" to treat pain, has got to stop!
There's also been little research about whether or not EMS in general "is any good"... But one thing we can absolutely help with is pain management...
In this case, Grandma is going to sit in a room in the ED, probably (despite being hypotensive) wait a while for an ED doc to see her, hes gonna write for labs, UA, and depending on whats at the top of his DDX (and its hard to tell with the limited info) either a KUB/abd series or a CT... One thing he's not going to do is, Hes NOT GOING TO WAIT FOR RESULTS BEFORE HE TREATS THE PATIENT'S PAIN!!!
If you dont have something in your box thats okay with Hypotension (Like Fentanyl) then perhaps you need to discuss your protocols with your Medical Director and ask what they want (i like the sound of MS with Benadryl {although have never tried it, as we dont have MS anymore})...Not treating people's pain is barbaric, and archaic...

 

[systemet]

Believe me - I get everything that y'all are saying. However...

I'm taking much of this in the context of the OP's case - abdominal pain of unknown etiology in a sick patient with a 7 minute transport time. In this particular case there is little if anything to be gained by managing this patient in the field. Regardless if it's my guess of bowel obstruction or whether it's a leaking aneurysm or SMA infarct - there just isn't much you can do outside the hospital. Now, if I'm out in the country with an hour transport time, I might consider other options, including judicious use of MS for pain. But with a short transport time and a far from certain diagnosis, I'm just not that hot on field management. If you're doing all these things while transporting, that's fine - although my guess is the OP has done several things (12 lead, blood sugar, IV, etc.) all while at the patient's residence. Again - for this particular case - O2, IV, transport would seem to be reasonable. I'll even go for a little morphine.

Fair enough.

While this patient would get seen quickly as they became hypotensive following an initial stable presentation, most of the patients I've transported complaining of abdominal pain have had to wait substantial periods of time prior to being assessed by an MD.

This is probably a result of the particular health care system I worked in, previously. We were expected to have provided analgesia, and would have been in trouble had we brought in a patient with severe pain that we hadn't tried to manage. We also might have to wait in the triage area providing further pain control for hours, depending on the given day.

I think liability issues mean that this probably doesn't happen much in the US, where I think most of the posters are from.

 

[Melclin]

Ah, this of course caught my eye as I was reviewing this thread.

Is there anywhere in the world this is used besides Australia? Use of MOF in anesthesia was abandoned 20+ years ago, at least in the US, and it's probably been 25 years since I've used it personally. I don't think it's even commercially available in the US in any form nowadays.

Never heard of it being used anywhere else but Australia, NZ and a few of our satellite countries that we mentor in various ways.

Its banned in America because people kept up and bloody dying. We no longer use it for anaesthesia for the same reason but its thought to be relatively safe in the smaller dose used for analgesia. Honestly, its the bees knees, especially for ortho trauma and procedural pain like applying a traction splint or moving a pt whose done his back in.

What I find interesting is that we use the same dose for everyone. For adults its fine, but you have to be careful with kids. I actually knocked a kid out cold once. I was a bee's **** away from ventilating him before he started to come good. :unsure:

 

[usafmedic45]

Its banned in America because people kept up and bloody dying

I believe it was actually related to an abnormally high incidence of kidney failure, if I recall correctly.

 

[Cavity]

agreed

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.

I feel the same way. Where I am my transport time is pretty much the same. 5-7 minutes to two hospitals. I would manage the b/p and by the time I checked it for the third time we'd be at the hospital. Plus I feel like treating undiagnosed abdominal pain was always something I was taught not to do.

 

[Melclin]

I believe it was actually related to an abnormally high incidence of kidney failure, if I recall correctly.

Yep, breaking people's piss factories with fluoride ions and some other nasty gear. As such we don't give it to people who have knackered kidneys already.

I seem to remember some stuff in our lectures about straight up spontaneous deadness being a reported side affect as well.