Pain relief and EMS

[mobey]

It sounds like you guys are calling what the rest of us know as PCP, ICP (With the exception of Alta. where EMT is used. Confused yet?). Do people doing a current PCP program license as ICP's following school?

PCP = BLS (6 mon program)

ICP= ILS (another 6 mos)

Ab EMT'S are not comparable to Sask ICP's.... half the education

[rock_shoes]

PCP = BLS (6 mon program)

ICP= ILS (another 6 mos)

Ab EMT'S are not comparable to Sask ICP's.... half the education

Gotcha. Sask. ICP's are another step in between PCP and ACP.

[Quakefire]

Gotcha. Sask. ICP's are another step in between PCP and ACP.

And it used to be a required step, not any more though. ICP's are treated as EMT-A, PCP EMT, and ACP EMT-P

[WelshMedic]

I guess I am a little late in answering this poll. My excuse is that I have just spent a week sampling lovely Bavarian beer in Germany. Now the guy/gal that comes up with effective pain relief for a hangover will win my vote for the Nobel prize for Medicine!

Pain relief is a subject close to my heart. One of the problems in EMS is that not enough time is spent on the subject during training. Those of us that have nursing backgrounds tend to have a more thorough understanding of the subject. Pain is a devastating mechanism that can even affect mortality and morbidity, particularly in the long term. It should be avoided at all costs! Would the BLS providers amongst us consider calling for ALS back-up for a # hip? I would hope so! Did you know that the mortality rate after 2 years for a hip fracture in the elderly is 80%!!!!. I am convinced that the initial management of these pts can influence that figure.

My own preference:

For the initial treatment and/or extraction of the patient: Ketamine in combination with midazolam

For ongoing treatment: in the elderly it's Fentanyl, in the young it's Alfentanyl (it's great stuff, but tricky to dose in the elderly).

All supplemented with iv paracetamol because it reduces the the amount of opiates the patients need in the medium to long term.

WM

[WelshMedic]

I guess I am a little late in answering this poll. My excuse is that I have just spent a week sampling lovely Bavarian beer in Germany. Now the guy/gal that comes up with effective pain relief for a hangover will win my vote for the Nobel prize for Medicine!

Pain relief is a subject close to my heart. One of the problems in EMS is that not enough time is spent on the subject during training. Those of us that have nursing backgrounds tend to have a more thorough understanding of the subject. Pain is a devastating mechanism that can even affect mortality and morbidity, particularly in the long term. It should be avoided at all costs! Would the BLS providers amongst us consider calling for ALS back-up for a # hip? I would hope so! Did you know that the mortality rate after 2 years for a hip fracture in the elderly is 80%!!!!. I am convinced that the initial management of these pts can influence that figure.

My own preference:

For the initial treatment and/or extraction of the patient: Ketamine in combination with midazolam

For ongoing treatment: in the elderly it's Fentanyl, in the young it's Alfentanyl (it's great stuff, but tricky to dose in the elderly).

All supplemented with iv paracetamol because it reduces the the amount of opiates the patients need in the medium to long term.

WM

[p3medic]

Would the BLS providers amongst us consider calling for ALS back-up for a # hip? I would hope so! Did you know that the mortality rate after 2 years for a hip fracture in the elderly is 80%!!!!. I am convinced that the initial management of these pts can influence that figure.

WM

Other than pain management (which is important) I don't see what an ALS provider would offer to reduce morbidity and mortality in these patients. The 2 year mortality rate may be 80%, but that is from complications down stream, not really something that a 30 minute ride in a BLS vs ALS ambulance is going to change. What initialy management do you suggest would improve the long term outcome of these patients?

[WelshMedic]

P3,

I'm not suggesting that we would cut mortality in half by decent initial pain management. However, I do think that it could play a role in reducing the figures. Poor pain management, whether it be pre-hospitally or otherwise, leads to poor wound healing, longer stays in hospital and extended revalidation periods. All of this has been researched, by the way, and is not just my unfounded opinion.

What I would therefore suggest is that EMS takes a leading role in providing decent pain management. Take the following example:

Doris, 80 yrs old, has taken a tumble in her kitchen. She is BLS'd (= no pain relief) into her local ER where she is put onto the corridor as a multi-vehicle MVA has just occurred. After an hour she is written up for opiates as pain relief by the ER attending. That therefore means that Doris has now gone almost two hours without any decent form of analgesia since her fall, but well, she doesn't like to complain because the nurses are so sweet, but oh so busy. Those busy nurses then leave Doris another 45 mins before they get around to administering the Morphine because of the back log of work.

Doris is finally given her pain relief almost 3 hours after her intial fall. She is ever so grateful and thanks everyone for their help before going up to the floor. It's just a shame that she was given such a poor standard of care. Now, we can all see why that happened and would be at pains not to point the finger at anyone. The fact, however, remains that she was left to lie in agony for three hours before her pain issues were adressed. You can bet your a$$ that it has affected her morbidity significantly in the long run.

All of you that have been in EMS for any length of time will recognize the above. It's fictitious, but let's face it, it could happen anywhere.

None of this need have happened, if Doris had been properly managed pre-hospitally then she would have a far more comfortable wait on that gurney. That's why we need to take a leading role.

WM

[Arizonaffcep]

p3, totally agree. The complications and mortality rate are due to (in part) the inactivity mandated by this type of injury. Plus elderly just don't heal as quickly or as well as younger folk. However, I do think pain management is imperative with these patients. The enemy of all fractures is movement, which is exactly what needs to be done to get the patient to the cot. I, assuming the situation allows for it, premedicate with morphine prior to movement. It's the human thing to do.

[p3medic]

Completely agree that pain management is warranted. It is the humane thing to do, no doubt. Early pain management is the goal, and it is certainly true that those who recieve pain management pre hospitally tend to recieve it sooner in the hospital. I haven't read any research suggesting that pain management early by EMS could reduce mortality in this group, but I don't doubt it exists.

[WelshMedic]

Lack of pain relief

Above is evidence that the problem is not limited to EMS.

And here a relevant quote from the Merck Manual of Geriatrics:

[quotePain management in the elderly has been addressed in clinical practice guidelines by the Agency for Health Care Policy and Research and by the American Geriatrics Society and in reports by the American Society of Anesthesiologists and International Association for the Study of Pain. Adequate pain management may improve cardiovascular and pulmonary function and, by preventing the stress response to postoperative pain, may lower the incidence of postoperative myocardial events. Decreased ventilatory function after thoracic or abdominal surgery is caused mainly by surgical trauma and by splinting due to postoperative pain. Pain management cannot restore ventilatory function but can help prevent splinting by enabling patients to breathe deeply and cough, thus improving mucus removal and avoiding atelectasis. Prevention of atelectasis reduces the postoperative risk of pneumonia and hypoxia.

Generally, adequate postoperative pain management helps patients walk sooner and improves functional status, hastening their return to the community. Pain management also enables patients to be discharged earlier, thus reducing medical care costs.