What is your opinion of pain management?

[ERDoc]

Aside from that, I feel like especially in an urban environment, and working in an ED where I can see the other side of the coin, I don't see the need for aggressive pain management with 10-15 minute transports. Likely by the time the med actually starts making a difference, you're pretty close to the hospital and giving things pre-hospitally messes up the ED "flow" if you will. For example, we do not give narcotics in the ED unless you are either getting admitted or have a ride home. If you are driving home, no candy for you. Most medics don't really think about that. Also, having the advantage of seeing a lot of our patient's EMR, you feel a lot more jaded when you see someone with 10/10 pain acute onset lower back pain, but they've been at the ED every month and have had 30 of hydrocodone filled a week ago.

Where do I even begin? Why should anyone have to suffer any longer than they have to? Paperwork is no excuse. You are being paid to take care of people and that is what you do. Paperwork is just part of the job. Yeah, you may be at the hospital in 10-15 minutes but it is going to be at least another 30 minutes before they get any meds in the ER. Do you want to suffer with a fractured hip for over 1 hour, when you could have been treated earlier? That is just cruel. Giving things in the field DOES NOT mess up any flow in the ER. There are plenty of people that get sent home that benefit from narcs (kidney stones, fractures, dislocations, DVTs, biliary colic, bad lacerations, pyelo, etc). Why would you not treat these people? Yes, driving home is a concern but that is not something EMS should be worrying about. We all have our frequent fliers and we know who they are. With experience, it becomes somewhat easier to identify who does and does not need narcotic pain meds. Always remember that even the frequent fliers actually get sick sometimes.

 

[NomadicMedic]

God that sounds terrible.

It, quite simply, blows.

 

[MonkeyArrow]

On the med control issue here, you contact the hospital that you're transporting too and speak with an ED doc there and that's base control for you.

And I'm obviously not advocating withholding pain meds from the obvious hip fracture/long bone fracture/whatever. But I said AGRESSIVE protocols and I still don't think you need to be medicating the questionable/grey area ones in urban environments. A crew once brought in a lady who jammed her finger in her car door with 50mcg of fentanyl on board. Sure, she may be in pain, but that's one I don't think I would have medicated.

 

[TransportJockey]

On the med control issue here, you contact the hospital that you're transporting too and speak with an ED doc there and that's base control for you.

And I'm obviously not advocating withholding pain meds from the obvious hip fracture/long bone fracture/whatever. But I said AGRESSIVE protocols and I still don't think you need to be medicating the questionable/grey area ones in urban environments. A crew once brought in a lady who jammed her finger in her car door with 50mcg of fentanyl on board. Sure, she may be in pain, but that's one I don't think I would have medicated.

If she's in pain, stable, and i have a minute you're damned right im going to medicate that finger. And 50mcg of fent is about half of our normal starting dose. Hell she sounds like a good candidate for intranasal fent

 

[TransportJockey]

Well, I guess it depends on where you are. At the service I'm working at PRN, giving ANY medication is a huge pain in the balls. Any Med, not just narcs. Even zofran.

If you open a message bag for anything, you break the numbered seal which then requires a full replacement bag at the ED.

SO... Before you can swap your med bag, you have to fully complete a PCR, print a copy, drive to the local base hospital, which is usually NOT where you've brought the patient, go to the pharmacy, (or find the night nursing supervisor if it's after hours) sign in your old drug bag, fill out a narc/med use form, waste any leftovers in front of the pharm (or RN if the pharmacy is closed), tape your now empty vial or carpo to the PCR and seal that in the OLD bag, get a new bag, break the pharmacy seal, count the contents, re-seal with a new numbered seal, sign a med bag form and then you're able to go run another call.

Biggest pain ever.

When I asked why we don't refill our bag from the Pyxis, they looked at me like I had two heads. "What? Give a paramedic access to the Pyxis? Never!!!"

Have I given fewer meds than I have in the past? Yep. You betcha.

I would be out of service so much they might reconsider that protocol

 

[cruiseforever]

Us old school guys were trained that way.

Not that that's an excuse for poor care, but the attitude towards prehospital analgesia has changed dramatically in just the past 5-10 years.

I agree with Remi. We used to call for orders when we wanted to give pain meds. If we were lucky the pt. with the open tib/fib fx would get 5 mg of Morphine. Changes were made 10-15 years ago, and now we can be very aggressive in treating pain, using Morphine, Fentanyl, Versed, and Ketamine.

But on the flip side of this. There is a strong push by the hospitals in the area to reduce the use of pain medications with pts. that have chronic pain issues or minor trauma. That has put pressure on us to be more selective in the pts. that will get pain meds. Example would be: Pt. has pain in his ankle after he tripped and fell. If there is no visible trauma such as deformity, swelling, bruising and B/P and pulse are within normal limits. He will not receive any pain meds. He will get a cold packs, position of comfort and a smooth ride to the ER.

While it maybe true that there are older medics that are not very good at treating a pt.'s pain. The same can be said about medics that are too loose in giving out the narcotics. They tend to be newer medics.

 

[chaz90]

On the med control issue here, you contact the hospital that you're transporting too and speak with an ED doc there and that's base control for you.

And I'm obviously not advocating withholding pain meds from the obvious hip fracture/long bone fracture/whatever. But I said AGRESSIVE protocols and I still don't think you need to be medicating the questionable/grey area ones in urban environments. A crew once brought in a lady who jammed her finger in her car door with 50mcg of fentanyl on board. Sure, she may be in pain, but that's one I don't think I would have medicated.

I'm not really seeing why the urban environment has so much bearing. Transport involves movement, and movement hurts. Some conditions hurt anyway, and we can start to get the pain under control long before the process can start at the ED, even if it is 5 minutes away.

After I get on scene with a patient with, say, kidney stones and severe flank pain, I can start an IV and administer meds in the first 5 minutes of patient contact as BLS prepares a stair chair and stretcher. If I didn't do that and left the patient hurting, extrication from the third floor back bedroom may take 10 minutes even if we're moving efficiently, loading into the ambulance another 2-3 minutes as we get everything reconnected and put away, 5 minute transport, 10 minutes waiting for a room/waiting for a nurse to transfer care, completing the registration process, having the nurse recognize the need for pain management and grabbing a doc/PA, having orders written, drawing from the PYXIS, and then finally administering them. This is assuming the ED isn't slammed with patient volume or high acuity too.

Even conservatively with the ED functioning fairly well, the time difference between me providing pain management on scene (as I have one patient to deal with and meds readily accessible) vs. transporting to an urban hospital and waiting can easily reach 30-45 minutes. I don't think that's an exaggeration in the slightest from EMS patient contact to hospital ED treatment even from a short distance away.

 

[reaper]

On the med control issue here, you contact the hospital that you're transporting too and speak with an ED doc there and that's base control for you.

And I'm obviously not advocating withholding pain meds from the obvious hip fracture/long bone fracture/whatever. But I said AGRESSIVE protocols and I still don't think you need to be medicating the questionable/grey area ones in urban environments. A crew once brought in a lady who jammed her finger in her car door with 50mcg of fentanyl on board. Sure, she may be in pain, but that's one I don't think I would have medicated.

Well, try this. Let me slam you finger in a car door and then tell me if you want pain meds.

Most EDs do not care what pts get pain meds. That is up to the medic on scene. It is up to you to assess your pt and treat accordingly.

Some medics act like they are using pain meds from their personal stash. Treat your dam pts!

 

[Bullets]

I don't disagree.. but true it is.. south alabama 12 trucks 5 counties. 10 of which ALS

You guys dont even have like ketamine for RSI or something? Fentanyl lozenges?

If you contact a hospital for base orders, don't you have to transport to that hospital?

Aside from that, I feel like especially in an urban environment, and working in an ED where I can see the other side of the coin, I don't see the need for aggressive pain management with 10-15 minute transports. Likely by the time the med actually starts making a difference, you're pretty close to the hospital and giving things pre-hospitally messes up the ED "flow" if you will. For example, we do not give narcotics in the ED unless you are either getting admitted or have a ride home. If you are driving home, no candy for you. Most medics don't really think about that. Also, having the advantage of seeing a lot of our patient's EMR, you feel a lot more jaded when you see someone with 10/10 pain acute onset lower back pain, but they've been at the ED every month and have had 30 of hydrocodone filled a week ago.

You guys call different hospitals for orders? We just call one hospital no matter where we are transporting too. Our OMLC is an hour north of us.

I dont think about some of these things because literally, i dont care. I dont care if they dont have a ride, if they are in pain NOW, then they get treatment NOW. When they are with me it is the only time the Provider/patient ratio is in their favor. I can provide pain relief now so when they get to the ER and wait 2 hours for a room and maybe 30 minutes or more between seeing one nurse they have some relief, because after i transfer care its going down hill.

As far as drug seekers, if the worst thing they can put on my tombstone is "Bullets trusted the patient and gave analgesia to too many people" ill rest peacefully. Im not the cops, its not my job to find out who is looking for drugs. If you tell me youre in pain and my assessment agrees with your chief complaint, then i will treat accordingly. What if that drug seeker is really in pain this time? Youre going to withhold treatment because of past experiances? Thats not my concern.

SO... Before you can swap your med bag, you have to fully complete a PCR, print a copy, drive to the local base hospital, which is usually NOT where you've brought the patient, go to the pharmacy, (or find the night nursing supervisor if it's after hours) sign in your old drug bag, fill out a narc/med use form, waste any leftovers in front of the pharm (or RN if the pharmacy is closed), tape your now empty vial or carpo to the PCR and seal that in the OLD bag, get a new bag, break the pharmacy seal, count the contents, re-seal with a new numbered seal, sign a med bag form and then you're able to go run another call.

Seems like a great way to avoid doing jobs when your busy or lazy...OOS restocking

 

[NomadicMedic]

Seems like a great way to avoid doing jobs when your busy or lazy...OOS restocking

Nothing great about it. It's seriously the most convoluted system I've ever seen.

 

[DesertMedic66]

You guys dont even have like ketamine for RSI or something? Fentanyl lozenges?


You guys call different hospitals for orders? We just call one hospital no matter where we are transporting too. Our OMLC is an hour north of us.

I dont think about some of these things because literally, i dont care. I dont care if they dont have a ride, if they are in pain NOW, then they get treatment NOW. When they are with me it is the only time the Provider/patient ratio is in their favor. I can provide pain relief now so when they get to the ER and wait 2 hours for a room and maybe 30 minutes or more between seeing one nurse they have some relief, because after i transfer care its going down hill.

As far as drug seekers, if the worst thing they can put on my tombstone is "Bullets trusted the patient and gave analgesia to too many people" ill rest peacefully. Im not the cops, its not my job to find out who is looking for drugs. If you tell me youre in pain and my assessment agrees with your chief complaint, then i will treat accordingly. What if that drug seeker is really in pain this time? Youre going to withhold treatment because of past experiances? Thats not my concern.


Seems like a great way to avoid doing jobs when your busy or lazy...OOS restocking

We have Base Hospitals that we have to contact for any orders we want and for some patients. Our other hospitals are just Paramedic Receiving Centers which means we can transport to them and we call them just to give them a heads up but we are not able to get orders from the hospital.

 

[RocketMedic]

I feel like Remi's viewpoint is exactly why people don't get adequate analgesia from most paramedics. Sure, there's plenty of situations where analgesia is unnecessary, inappropriate with opiates or can be accomplished with alternative measures, but the Remis and cruiseforevers and Monkey arrows of the world don't all differentiate between those cases and cases where opiates are indicated and quite helpful.

 

[Carlos Danger]

I feel like Remi's viewpoint is exactly why people don't get adequate analgesia from most paramedics. Sure, there's plenty of situations where analgesia is unnecessary, inappropriate with opiates or can be accomplished with alternative measures, but the Remis and cruiseforevers and Monkey arrows of the world don't all differentiate between those cases and cases where opiates are indicated and quite helpful.

Yep. Folks like me are definitely the reason people don't get adequate analgesia from "most paramedics".

What do I know, after all?

Edit: and the term is "opioid", not "opiate". Please at least learn the basic terminology before you try lecturing me about this stuff.

 

[teedubbyaw]

What do I know, after all?

 

[epipusher]

Yep. Folks like me are definitely the reason people don't get adequate analgesia from "most paramedics".

What do I know, after all?

Edit: and the term is "opioid", not "opiate". Please at least learn the basic terminology before you try lecturing me about this stuff.

Yet again I support Rocket in another Remi v. Rocket discussion. This last post speaks volumes.

 

[RocketMedic]

It had better be real and severe before I'm happy giving anything. Absent any obvious injury.. the more drama, the less real I think it is. They start saying they're allergic to everything except what they want? My Bull Sh*t detector goes off!

And what, pray tell, is your definition of "real and severe?"

 

[46Young]

We have Fent 1mcg/kg, max single dose of 100mcg, max total of 200mcg, and we can call for more. 1/2 single dose, but same cumulative dose for pts 65 y/o or older. We carry 400mcg on our rigs. We're now able to incorporate Ketamine into pain management as well. Burn pts. and pts already on opiods may need more than 200mcg, but otherwise what we have does a decent job most of the time.

PPW and OOS time for restock is not a concern. It takes me 10-15 minutes tops to do the waste, get signatures, and get a new narc pouch from the pharmacy.

As far as seekers/frequent fliers, a little psychology and observation is needed. I try to get them distracted with some in-depth conversation, and see if they forget to act like they're in pain for a moment or two. When you have more than two minutes on the job, you'll see who's really suffering, and who's putting on a show to get some free drugs. I've had plenty of psych patients be chill during txp, and then become profoundly combative as we pull into the ED, knowing that they'll be chemically restrained with goodies like Versed, Ketamine, and Haldol from the ED staff.

Having said that, if a patient appears to be in withdrawal, it is barbaric to let them suffer when you could give them some Fent, which is fairly short acting and isn't very strong, which may curb their withdrawal Sx. If the patient is just putting on a show, where they present normal when you engage them in conversation, then act ill in the interim, the simple solution is to start the line two minutes away from the hospital so you're taping the line down as your partner is opening the doors, or document their pain scale according to FACES instead of the numeric scale, to keep QA/QI off of your back.

I may or may not have given a placebo NS flush once or twice back in the day, with an "observable reduction in perceived pain." lol

 

[teedubbyaw]

Max single dose of 100? Pfft. My last tib/fib guy got 200 off the bat, finishing at 300. Would have given him another 100 if time permitted. So many protocols are uptight with fentanyl.

 

[RocketMedic]

If I'm not going to give meds, I simply don't bring it up.

For what it's worth, the placebo effect is not ethical and I do not think it is a good or supportable practice.

 

[Akulahawk]

I'm a big fan of giving pain control. Unfortunately, where I work, we see a LOT of drug seeking behavior. Of course we also see a LOT of kidney stones. There's a very good drug that we use a LOT... Toradol. Yes, it's a NSAID and there are reasons NOT to give it. However, I've seen patients get more relief out of some Toradol than with morphone or dilaudid. Those patients that are seeking usually get really angry at the Toradol offer... Darned near every patient that has gotten Toradol (that can get it) usually end up back in the ED asking for it. They get nothing out of it except relief.

When I was working in the field, I would have really liked to have a non-narcotic IV option... and Normazaline isn't a good substitute or good medicine.