What is your opinion of pain management?

[NomadicMedic]

Wow. Where in CT is this? It seems as though I recall and over abundance of medics. (At least in eastern CT)

 

[EMTinCT]

Wow. Where in CT is this? It seems as though I recall and over abundance of medics. (At least in eastern CT)

Not in CT. Where I lived in Montana a few years back.

 

[johnrsemt]

With an hour to extricate why didn't you call for a helicopter? I have seen Helicopter services come in and give pain meds in a case like that and then leave for the patient to be transported by ground. Doesn't happen much, but does. Also seen the flight medic ride in on the ambulance with the patient.
And your service does not pay for the medic, the patient does (and if they don't pay then the ALS service eats it, just like your service eats it if the patient doesn't pay for your services). At least that is the way that all insurance companies do it in the US.

We carry 20mg of Morphine and 200mcg of Fentanyl; and can give all of either without contacting a doc; but we have minumum of 45 minute transport to closest hospital. and I have actually had 95 minute transport to closest hospital. Level II and Level I hospitals are minimum of 80 minutes away.

 

[johnrsemt]

and opinion of pain management is that prehospital it is NOT done enough. Proven time and again that people in less pain heal faster.

With a lot of patients we can't do much else for them, why make them hurt more.

In my old service I had a medic brag that in 12 years she had NEVER given Pain meds; then in the next sentence she told me that if she was ever hurt she wanted me to take her to the hospital.
One day she called for me to intercept for pain management (she had an employee that fell down the stairs and hurt her leg)., I thought it was cause she started transporting without grabbing narcs; no she just refused to push pain meds, but didn't want to hear the patient scream anymore.

 

[Clare]

In my old service I had a medic brag that in 12 years she had NEVER given Pain meds; then in the next sentence she told me that if she was ever hurt she wanted me to take her to the hospital.
One day she called for me to intercept for pain management (she had an employee that fell down the stairs and hurt her leg)., I thought it was cause she started transporting without grabbing narcs; no she just refused to push pain meds, but didn't want to hear the patient scream anymore.

Surely you are joking? That is absolutely abhorrent and disgusting. I cannot accept that you are not somehow joking honestly.

If you are not joking, then I am at a loss to understand how this was not identified by clinical support or auditing processes, or better yet, by voluminous patient complaints to either your service individually, to whatever you call the Ministry of Health or patient advocacy people in the US.

I also presume if you are not joking that you made a very loud official complaint to both your clinical standards or development function and whatever regulatory authority is responsible for ambulance personnel in the US because that is nothing but negligence. Absolute, complete and unequivocal negligence and failure to provide care of an appropriate standard. And if you did not, then you are just as negligent.

I do not think anything I have seen or heard in my time in the ambulance service makes me more disgusted. And I have seen some pretty horrific things.

 

[Underoath87]

We're in the process of switching to fentanyl from morphine and dilaudid, but many medics are unfortunately under the impression that it is weak and often doesn't help much, since we are limited to 100 mcg per pt.
For IV: 1 mcg/kg (max of 50 mcg), can be repeated once after 5 minutes.
IM or IN: 2 mcg/kg, max of 100 mcg.

We have ketamine, but can only use it for RSI.

 

[chaz90]

We're in the process of switching to fentanyl from morphine and dilaudid, but many medics are unfortunately under the impression that it is weak and often doesn't help much, since we are limited to 100 mcg per pt.
For IV: 1 mcg/kg (max of 50 mcg), can be repeated once after 5 minutes.
IM or IN: 2 mcg/kg, max of 100 mcg.

We have ketamine, but can only use it for RSI.

There's a fair number of patients that I administer more than 50 mcg Fentanyl, even on the initial dose. Restricting the entire dose to a max of 100 mcg is pretty ridiculous too. It's funny that your protocols are so strict regarding Fentanyl when you're coming away from Morphine and Dilaudid. Really, fentanyl is much easier to manage and has a better side effect profile than those two. What were your dosing guidelines for Morphine and Dilaudid?

 

[Underoath87]

There's a fair number of patients that I administer more than 50 mcg Fentanyl, even on the initial dose. Restricting the entire dose to a max of 100 mcg is pretty ridiculous too. It's funny that your protocols are so strict regarding Fentanyl when you're coming away from Morphine and Dilaudid. Really, fentanyl is much easier to manage and has a better side effect profile than those two. What were your dosing guidelines for Morphine and Dilaudid?

Max of 2 mg for dilaudid and 10 mg for morphine. But they could receive both. So obviously 100 mcg of fentanyl seems weak by comparison.

 

[EMTinCT]

With an hour to extricate why didn't you call for a helicopter? I have seen Helicopter services come in and give pain meds in a case like that and then leave for the patient to be transported by ground. Doesn't happen much, but does. Also seen the flight medic ride in on the ambulance with the patient.
And your service does not pay for the medic, the patient does (and if they don't pay then the ALS service eats it, just like your service eats it if the patient doesn't pay for your services). At least that is the way that all insurance companies do it in the US.

We carry 20mg of Morphine and 200mcg of Fentanyl; and can give all of either without contacting a doc; but we have minumum of 45 minute transport to closest hospital. and I have actually had 95 minute transport to closest hospital. Level II and Level I hospitals are minimum of 80 minutes away.

We did but there was no landing zone for 10 miles.

 

[sir.shocksalot]

I do not think anything I have seen or heard in my time in the ambulance service makes me more disgusted. And I have seen some pretty horrific things.

Here in the good ol' US of A our EMS systems are so fractured with next to no oversight that some EMS providers can almost literally get away with murder. Taking action on a provider's certification varies by state and, in my experience, occurs very infrequently. It's not like filing a grievance against a doc or a nurse. And even revoking a provider's certification in one state won't necessarily preclude them from working in EMS in another state. Unfortunately, there is no mandatory federal oversight for EMS providers, no mandatory reporting of care, treatments, transport, or anything really. The onus is upon each agency and their medical director to police the care (or lack thereof) given by providers. EMS as a whole in the US is an embarrassment compared to most other places. The agencies that are doing it right aren't any different on paper than the ones that give shoddy care with outdated protocols or a complete lack of necessary equipment. Maybe one day we can have mandatory reporting and quality measures tied to medicare/medicaid reimbursement like every other healthcare profession in the country.

We're in the process of switching to fentanyl from morphine and dilaudid, but many medics are unfortunately under the impression that it is weak and often doesn't help much, since we are limited to 100 mcg per pt.
For IV: 1 mcg/kg (max of 50 mcg), can be repeated once after 5 minutes.
IM or IN: 2 mcg/kg, max of 100 mcg.

We have ketamine, but can only use it for RSI.

100 mcg just doesn't cut it with Fentanyl. Doses can easily end up going well over 400mcg before getting control of some pain. Sometimes Fentanyl has to be mixed with Versed or valium before pain starts to become manageable. It's all really patient dependent to the point that medical directors need to give a lot of latitude to paramedics to treat pain with whatever doses and mixes they need to get the job done. It's sort of sad that you can RSI but not give Fentanyl in reasonable amounts. Ketamine is also very effective for pain in low doses, there is quite a few agencies in CO using it for pain along with the military. You should see if you can sell your medical director on the idea by giving him a few studies showing it's safety and efficacy.

 

[TRSpeed]

Kern County Fent standing order of max 200mcg. 20MG Morphine . We can call for more. Carry 800mcg Fent, 40mg MS, 30mg Vallium, 16mg Versed just got rid of Ativan :/.

 

[Carlos Danger]

100 mcg just doesn't cut it with Fentanyl. Doses can easily end up going well over 400mcg before getting control of some pain. Sometimes Fentanyl has to be mixed with Versed or valium before pain starts to become manageable. It's all really patient dependent to the point that medical directors need to give a lot of latitude to paramedics to treat pain with whatever doses and mixes they need to get the job done. It's sort of sad that you can RSI but not give Fentanyl in reasonable amounts. Ketamine is also very effective for pain in low doses, there is quite a few agencies in CO using it for pain along with the military. You should see if you can sell your medical director on the idea by giving him a few studies showing it's safety and efficacy.

I agree that arbitrary limits are not in the best interest of patients. On the other hand, neither is giving tons of narcs just so you can brag about how "aggressive" you are with pain management. Which is not unheard of in some EMS circles - we all know the type. So while I don't like seeing "hard limits" in terms of max doses, I also don't think it's unreasonable to have to call OLMC once you get above a certain dose.

I would not say that "100 mcg doesn't cut it with fentanyl". It depends on the severity of pain and other factors, of course. 50% TBSA burns? Yeah, there's a good chance you'll need a lot more than 100 mcg. Chronic pain patient who already takes lots of opioid and now has a hip fracture from a fall? Might as well draw up a couple vials from the start. But outliers like those aside, you don't usually need a ton of fentanyl. If you are routinely going over 2, definitely 3 mcg/kg or so in order to manage "typical" pain, I'd have an independent lab do a QC on the potency of your fent. Either that, or re-evaluate what specifically you are trying to achieve with your analgesia.

 

[evantheEMT]

Depends what als has just because you give pain meds onscene doesn't mean it will help them. I know some places carry the least amount that really doesn't help.

 

[Tigger]

Depends what als has just because you give pain meds onscene doesn't mean it will help them. I know some places carry the least amount that really doesn't help.

It will certainly help more than giving none. Your second sentence does not make sense.

 

[evantheEMT]

It will certainly help more than giving none. Your second sentence does not make sense.

Of course it does they carry so little that there's no point to even given it.

 

[TransportJockey]

Of course it does they carry so little that there's no point to even given it.

Granted, most of my time is in rural areas, but I haven't seen a service carry less than 200mcg Fent and/or 20mg MS (plus my last rural 911 job before this we carried 400mcg Fent, 40mg MS, 10mg Dilaudid, and quite a bit of Demerol (depending how much was on backorder)). 200 and 20 is a perfectly good amount to carry. I've never seen a service, even urban services, carry 'too little'

 

[DesertMedic66]

I quite often max out standing orders for pain medications on our hip fracture patients. A simple call to the hospital for additional pain meds is a very simple thing to do.

 

[NomadicMedic]

Of course it does they carry so little that there's no point to even given it.

This is something I hear from old medics who don't want to crack open the seal on their drug box. Sounds like a line of crap that the OP took as gospel.

 

[Tigger]

Of course it does they carry so little that there's no point to even given it.

Grammatically it was impossible to understand. And no service carries to little, a single vial of fentanyl is often more than enough for one patient. You do not know what you speak.

 

[H33]

Much to my sorrow while our state allows pain control by several means it does not require it, so alas we do not carry it. It's quite nice when we average 60 mile 911 transports.. ma'am bite down on the leather strap and curse if you feel the need..