For you medics out there? A chest pn question

[chute]

Fentanyl has a better side effect profile than Morphine in my opinion. Use of both in the prehospital arena is a Medical Directors decision based on cost issues and preference. It's nice to have multiple tools in the box though depending on where your at. Same issue with Phenergan vs Zofran. Depends on MD preference and cost (and kingdom rules ha ha). Certainly a dynamic issue! Thanks

[AlamanceMD]

....it would seem having options would be a good thing for your paramedics that are properly educated. Does morphine still have a place in pain management of any sort or should it be completely done away with?

Thanks for the welcome!

Re: replacing morphine with Fentanyl vs. adding Fentanyl and keeping morphine -

As another reply has stated, Fentanyl has a better side effect profile, I prefer it in trauma, and we now need to question the benefit of morphine in chest pain. I see no need to keep morphine.

I think there are false anecdotes that build up about medicines. I see it with medics, nurses, and docs. The false conclusion is that, when using two drugs on a patient because the first dose of one med was inadequate, the last drug given, which gets the desired result, is the best. The truth is we should be using a higher initial dose or just using the one best med to a therapeutic level.

I'm afraid this would happen if we had two drugs on the ambulance. Try this, try that, and the last thing you used is the best. Why make decisions in that manner? Let's decide what we're going to do, what we're going to use, in advance and use it. And in a service with relatively short transport times, why not use Fentanyl?

And I'm not a big fan of too many options in the truck. I put Amiodarone on the truck and took lidocaine off. Why leave both on when I think amiodarone is better? What criteria should I tell the medics to use to choose one over the other? Same questions come up when talking about morphine and Fentanyl.

Please let me know what I'm missing with this logic and what I should consider when trying to give medics options on the truck.

Regards,

AlamanceMD

[Mateo_1387]

I think there are false anecdotes that build up about medicines. I see it with medics, nurses, and docs. The false conclusion is that, when using two drugs on a patient because the first dose of one med was inadequate, the last drug given, which gets the desired result, is the best. The truth is we should be using a higher initial dose or just using the one best med to a therapeutic level.

This problem needs to be addressed with all your paramedics. Do you think that doctors, nurses, and medics are doing it because of ignorance? Maybe they just do not know better, and need to have it addressed in their education.

I'm afraid this would happen if we had two drugs on the ambulance. Try this, try that, and the last thing you used is the best. Why make decisions in that manner? Let's decide what we're going to do, what we're going to use, in advance and use it. And in a service with relatively short transport times, why not use Fentanyl?

Good point. It is generally not good medical practice to mix and match medicine just to "try" it. Our actions should be guided by evidence, and not done in a "just to see" manner. Your desire for the medics to use one narcotic needs to be known. Also, having more than one narcotic may be applicable for patients who have allergies, or may be sensitive to certain narcotics.

Generally protocols are great to have as guidelines. An already made plan allows for uniformity to patient care, as well as gives us a good guide during stressful situations. There does not need to be a "one protocol fits all patients with xyz condition" mentality. Paramedics can be protocol monkeys, but that is not what is good for the patient. The paramedic needs to have a full understanding of the patients condition, and why xyz treatment is being used. There will be cases where the "formula" will not work, and treatment can be detrimental to the patient. There has to be thinking on the medics part. Would the same criteria you use to decide which narcotic is appropriate also be used by your paramedics?

Just saying...........If I have severe pain, yet I am allergic to the drug you carry, I am still not going to be very comfortable even though transport times are short. The availability of multiple medicines can mean better customer service.

And I'm not a big fan of too many options in the truck. I put Amiodarone on the truck and took lidocaine off. Why leave both on when I think amiodarone is better? What criteria should I tell the medics to use to choose one over the other? Same questions come up when talking about morphine and Fentanyl.

Just curious, why are you not a fan of too many options in an ambulance? One you stated was the potential to use multiple medications to cause a desired effect, when the effect could be reached with one medication. I am guessing there are more.

Lidocaine could be left on the ambulance for cases of severe head trauma. How about Toradol with kidney stones? It would be a great medicine to have in place for kidney stone pain. There is always the chance that the Toradol does not cause the desired effect to relieve pain, where consideration of a narcotic may be applicable.

Please let me know what I'm missing with this logic and what I should consider when trying to give medics options on the truck.

You should know you paramedic's abilities, strengths and weakness. It can be a bad decision to give many options to the paramedics when they may not fully understand why one option is better than another. Trust is a big issue when deciding what options go on the truck. If it is out there, find research that may cover an issue with your service when deciding which option is best. You can always use internal statistics too !

[chbare]

I think much will depend on the service and mission profile. When we eliminate specific therapies we can limit our ability to intervene when conditions such as true allergies and medication interactions arise. However, letting providers run amuck with unlimited access to interventions can result in massive acts of commission. A balance is needed. This will require allot of physician involvement with the service and hopefully customized guidelines that will meet the needs of the providers and the mission profile.

Some information to consider regarding lidocaine. I can find no solid evidence that lidocaine actually benefits the head injured patient. Of course, no real evidence exists that says lidocaine is harmful. So, like many things in medicine, something becomes a standard of care with no real evidence to support it's use. High flow oxygen for every patient for example? In addition, if you look at many of the guidelines, many people recommend that you need to give the lidocaine several minutes prior to laryngoscopy for it to be of any benefit. Pretty hard to do in many cases of RSI. Then, what about services who do not use RSI?

The use of Toradol may be a good idea; however, Toradol is a very powerful NSAID, and we should not take lightly the risks associated with using Toradol. Several black box warning exist for Toradol. Problems such as GI bleed, adverse cardiac and neurologic events, coagulation disorders, and renal damage are all serious problems associated with the use of Toradol.

Take care,

chbare.

[Mateo_1387]

Some information to consider regarding lidocaine. I can find no solid evidence that lidocaine actually benefits the head injured patient. Of course, no real evidence exists that says lidocaine is harmful. So, like many things in medicine, something becomes a standard of care with no real evidence to support it's use. High flow oxygen for every patient for example? In addition, if you look at many of the guidelines, many people recommend that you need to give the lidocaine several minutes prior to laryngoscopy for it to be of any benefit. Pretty hard to do in many cases of RSI. Then, what about services who do not use RSI?

I know of no such information supporting the use of lidocaine. The use of lidocaine for a head injury does not have to be specific to RSI. It may be used in conjunction with nasotracheal intubation, and also oraltracheal intubation, even without a gag reflex.

[chbare]

You are talking about lidocaine jelly and the use of topical lidocaine? I agree that using lidocaine jelly and neo for nasal intubation is quite helpful. However, no strong evidence exists supporting the use of lidocaine to blunt ICP changes in the head injured patient. Then again, nothing saying it is harmful.

Take care,

chbare.

[Mateo_1387]

Lidocaine Jelly may be used for intubation, but I was in reference to IV Lidocaine, in order to lower ICP, and also blunt nerve transmissions. It would be interesting to find out what studies would say, if they are ever done. It always makes me wonder if what we are doing is "right" even though we really do not know. I am sure we will find out sooner or later.