What is your opinion of pain management?

[cruiseforever]

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.

Not sure where you got the idea that I am unable to differentiate between pts. that need pain control and those that do not? I feel I do a very good job of treating my pt's. pain and I would think most of my pts. would agree.

 

[triemal04]

Not sure where you got the idea that I am unable to differentiate between pts. that need pain control and those that do not? I feel I do a very good job of treating my pt's. pain and I would think most of my pts. would agree.

Don't. Please, please don't start. The last 3 months have been very nice, so before you get involved in what you think will be an open debate, maybe check out the post history. It's enlightening.

 

[RocketMedic]

The same can be said about medics that are too loose in giving out the narcotics. They tend to be newer medics.

And what is "too loose"?

 

[NomadicMedic]

And what is "too loose"?

You know it when you see it.

A woman on her cell phone, complanning of 10/10 foot pain, does not need 100 of fent.

A woman with an angulated fx of her tib/fib, moaning in pain, does.

I know several medics who would medicate neither and another medic who would medicate both.

Too tight and too loose.

Determination of actual pain is difficult, but experience and situational awareness will usually help in guiding your pain management practice. Unless, of course, you have no skill in reading nuance...

 

[cruiseforever]

You know it when you see it.

A woman on her cell phone, complanning of 10/10 foot pain, does not need 100 of fent.

A woman with an angulated fx of her tib/fib, moaning in pain, does.

I know several medics who would medicate neither and another medic who would medicate both.

Too tight and too loose.

Determination of actual pain is difficult, but experience and situational awareness will usually help in guiding your pain management practice. Unless, of course, you have no skill in reading nuance...

That sums it up nicely.

 

[RocketMedic]

That sums it up nicely.

Yet your original post comes across as that of an angry old man, yelling at clouds. "Their vitals need to reflect pain"- type logic.

 

[Chewy20]

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.

Post your protocols.

 

[EpiEMS]

You know it when you see it.

A woman on her cell phone, complanning of 10/10 foot pain, does not need 100 of fent.

A woman with an angulated fx of her tib/fib, moaning in pain, does.

I know several medics who would medicate neither and another medic who would medicate both.

Too tight and too loose.

Determination of actual pain is difficult, but experience and situational awareness will usually help in guiding your pain management practice. Unless, of course, you have no skill in reading nuance...

I would tend to say it's hard to design a system (especially a large one) where "you know it when you see it" leads to the same outcomes across many providers. That's where good protocols or some sort of overriding assumption come(s) into play. Not to say that a qualitative reasonableness standard isn't good, just that it's insufficient on its own.

(I'm not entirely qualified to speak on this, of course, being that I'm limited to positioning, splinting, and hot/cold packs, which are often wholly inadequate...)

 

[SeeNoMore]

We operate under fairly liberal protocols are are expected to treat pain , and document a management strategy that includes the patient's wishes if they are able to make their needs known. For example, an individual might get an initial dose of fentanyl and then determine that their pain is at an acceptable level vs additional meds. I err on the side of providing at least some pain management to any patient who complains of pain, and would like pain meds. If a complaint of pain seems exaggerated I might follow up an initial dose with the statement "I've given you something for the pain, we will be at the hospital soon and they can give you more." If it's a long transport I will still follow this up with another check in / discussion about their pain and usually more meds. I don't view it as my place to determine whether someone is faking , but of course I don't necessarily empty the drug box on someone complaining of 10/10 pain with no apparent distress, no abnormal v/s, etc.

 

[Akulahawk]

You know it when you see it.

A woman on her cell phone, complanning of 10/10 foot pain, does not need 100 of fent.

A woman with an angulated fx of her tib/fib, moaning in pain, does.

I know several medics who would medicate neither and another medic who would medicate both.

Too tight and too loose.

Determination of actual pain is difficult, but experience and situational awareness will usually help in guiding your pain management practice. Unless, of course, you have no skill in reading nuance...

For those, I'd say to get be sure to ask in-depth about the PMH. Sometimes you find something that just tells you the patient isn't drug seeking.

 

[cruiseforever]

Yet your original post comes across as that of an angry old man, yelling at clouds. "Their vitals need to reflect pain"- type logic.

Angry old man, not yet. Still in the grumpy old man stage.

The post you refer to is an example of what our medical director wants done if the injury does not appear to equal the amount of pain the pt. is complaining of. He feels if the person's pulse is not elavated, does not c/o nausea, or is diaphoretic, to be cautious in treating their pain. But to take in account the pt. maybe on Beta blockers and other meds. that may affect the pt.'s vitals.

The medical community in our area has decided to be more selective on ways to treat pain, instead of just pumping them full of narcotics. That in turn has caused us to be more selctive on how we treat our pts.. Since we have made changes in treating pain, we have recieved very few complaints from the pts. about not treating their pain. And the number of complaints from the ERs about over medicating a pt. has decreased.

 

[triemal04]

The medical community in our area has decided to be more selective on ways to treat pain, instead of just pumping them full of narcotics. That in turn has caused us to be more selctive on how we treat our pts.. Since we have made changes in treating pain, we have recieved very few complaints from the pts. about not treating their pain. And the number of complaints from the ERs about over medicating a pt. has decreased.

Like the medical community at large really. Except of course for EMS that is (since EMS is generally 5-10 years behind the times that really isn't surprising). Apparently blatantly handing out gobs of narcotics to anyone who uses the word "pain" is a bad idea. Who knew?

 

[NomadicMedic]

For those, I'd say to get be sure to ask in-depth about the PMH. Sometimes you find something that just tells you the patient isn't drug seeking.

Right, but read the REST of what I posted...

Determination of actual pain is difficult, but experience and situational awareness will usually help in guiding your pain management practice. Unless, of course, you have no skill in reading nuance...

 

[CALEMT]

A woman on her cell phone, complanning of 10/10 foot pain, does not need 100 of fent.

 

[UpstateMedic4459]

There are several Albany area services that do the same. It's not a required medication, so they don't carry it and therefore avoid "regulatory" issues.

I've noticed that some of the ALS Fire Departments Up here only the Rescue Rig or the Chief are the only ones who carry them

 

[Inspir]

Morphine is still our go to for pain management. We have fentanyl but our protocol reserves it for poly-trauma or morphine allergy patients.

We also carry entenox which you can administer concurrently with morphine or fentanyl which works great.

 

[usalsfyre]

Like the medical community at large really. Except of course for EMS that is (since EMS is generally 5-10 years behind the times that really isn't surprising). Apparently blatantly handing out gobs of narcotics to anyone who uses the word "pain" is a bad idea. Who knew?

Except that EMS and EM treatment of acute pain never has been, and still isn't, what's caused the opioid issue in the US. Core measures forcing long-term narcotic scripts followed by the DEA yanking the rug out from under opiate-dependent patients has led to the current heroin crisis.

 

[Inspir]

I look at it from the perspective if I was the patient. If I was in any pain I don't want to feel a thing. And having the unfortunate event of breaking a femur I am glad I had an ALS crew who were very liberal with pain management.

 

[Carlos Danger]

I look at it from the perspective if I was the patient. If I was in any pain I don't want to feel a thing. And having the unfortunate event of breaking a femur I am glad I had an ALS crew who were very liberal with pain management.

I'm not sure you really meant "not feel a thing", so I'm not picking on you at all, just using this statement as an example of something that we hear all the time, and is actually quite problematic. Many people DO mean they don't want to feel a thing.

The expectation that pain should never exist at all is unrealistic, unreasonable, and ultimately even counterproductive to the overarching goals of our healthcare system. Unfortunately, this expectation has been heavily reinforced since the 1990's, to the point that a patient's satisfaction with their care (which is highly subjective and variable and dependent on many individual factors, of course) is dependent largely if not mostly on their perception of how well their pain was managed. Give patients enough of "that one that starts with a D" and they are satisfied with their care. Don't give them enough and they aren't satisfied. Little else matters to many people. Except of course how long they have to wait to get "that one that starts with a D".

For a couple decades now patients have been told that they are entitled to be pain free, and if that requires a large supply of potent opioids, then they have a right to those drugs. Accordingly, doctors and facilities have been punished for trying to take a more moderate and reasonable approach to analgesia. We are all familiar with where this has led us. It has in at least some cases shifted the focus from areas of care that are more important, it has exposed a huge part of the population to doses of opioids that were not necessary or safe, and it has seriously skewed many people's perceptions of what constitutes quality medical care. Now in an effort to combat the problems caused by this approach, the pendulum is beginning to swing back in the opposite direction, and that won't be a good thing either.

The reality is that pain is a normal physiologic response (and experience) to injury or illness. It is just one of the many unpleasant facts of life that everyone will go through. If you have surgery or suffer a traumatic injury, it is going to hurt. The only way to make it not hurt at all is to expose you to large doses of powerful chemicals that can have untoward effects on your physiology and your psychology. Yes, there are problems with not managing pain. But no one is suggesting that we not manage pain. Part of managing pain properly is having a realistic expectation of it.

What does this have to do with EMS? Am I saying we shouldn't treat pain? It really doesn't have a whole lot to do with EMS, because for the most part we aren't talking about problems arising from the very early phases of managing an acute injury, in which case we should of course treat severe pain. But many folks in EMS now weren't around in the days before everyone was on opioids, and seem to have the same misperceptions about pain and what is reasonable for patients to experience. All the comments you see on this and other EMS forums to the effect of "there's no reason patients should be in pain at all" reflect a misunderstanding of effective pain management and in at least a small way, contributes to the larger problem.

 

[SpecialK]

Treatment of acute pain is one of the best things ambulance personnel can do.

Our patients are fortunate to have a great many options available to them depending on how severe their pain is:

Paracetamol
Ibuprofen
Tramadol
Entonox
Methoxyflurane
Morphine
Fentanyl
Morphine or fentanyl plus midazolam
Ketamine
Lignocaine 1% ring blocks

Many patients only require inhaled pain relief plus the oral triple combo (paracetamol, ibuprofen and tramadol) once they are in a position to swallow the tablets which takes care of the acute pain and means they won't have an immediate need for pain relief when arriving in hospital. If the patient has a minor condition and does not need immediate referral to somebody else then they can be left with a blister of paracetamol and ibuprofen for later on as well as being given a stat dose.

Morphine is great for most acute pain but big doses are not very nice on some folk so fentanyl is good for these patients, and is also good when trying to analgise somebody who is a little bit on the poor side. Since we got ketamine about 10 years ago I just couldn't live without it anymore, most wonderful stuff I have ever seen. Lignocaine ring blocks 1% are pretty nifty, I haven't used them but the thrust of the idea of providing local instead of systemic analgesia is a good one. Who knows, it might be extended at some point to hands or wrists or ankles.