Should you withhold Pain Meds if close to hospital?

[EMS49393]

I called for a medic once as a Basic because we had a 60 YOF with a nasty nasty fracture/dislocation of her ankle and we literally could not even feel for a pulse without her screaming. When the medic got there they didn't even come in with any bags and pulled me outside the house and said to clear them because it was a simple BLS call. I stood my ground and said I will not until you go try to asses that patient and tell me that she is not a candidate for pain management protocol. As soon as the medic really looked at her, he started a line and gave morphine so we could splint and get her down the stars to the unit.

I was so pissed that he wanted to leave without even seeing the patient and didn't want to give any drugs until he realized we weren't going to be able to splint it without causing her immense pain.

GRR still pisses me off when I think about that call.

That's exactly why most of the basics I work around will not call for any sort of ALS upgrade. I'm sure it's hard to hear a medic tear you apart because you felt their services would be necessary and were rude enough to drag them away from their movie, nap, or internet time. How dare you presume to think they should do their job. I took a job with a company that was transitioning from BLS to ALS a few months ago. It's the lazy medics they've had to deal with that are making my transition so difficult. I tell these guys over and over to call me if the need me. I tell them I don't mind coming out and taking a call if they are the slightest bit unsure about anything. I also tell them to call me when they know they have a patient that needs pain medication. Most of the basics here are so used to splinting in place and listening to the patient scream all the way to the ER. They're simply afraid to call a medic here because they will more often then not berate them for calling and proceed to provide no additional care. I don't really care how burned out someone is either. If they're burned out and crusty, they need to go find a nice janitorial or food services job somewhere.

If you know you have the ability to make a patient more comfortable, you should be doing it. It's about the best interest and best treatment for the patient, period.

Edited October 12, 2009 by EMS49393

[Lone Star]

Simply by replying, I am in over my head. I say that because I'm a 'lowly EMT-B/EMT-I student (yes, said tongue in cheek).

I'm not able to administer analgesics...yet.

If I WERE in the position to be able to relieve my patients pain (even a little bit), I would.

I agree that any competent physician can properly assess the patient we bring them even if they're stoned out of their gourds. If it's an inconvenience versus patient comfort, patient comfort will rule any day.

If your protocols on pain management aren't restrictive based on distance, and there's no underylying contraindications; then by all means, give your patient some relief!

As Dust said, make sure your documentation ducks are all in an orderly group. If worse comes to worse, I'd present the reciving facility the passages of the protocols that you're following, (yes, I've done that before!). Ultimately, it's those protocols that will either hang you or save your ass.

No, we're not in the business of making the recieving facility staff's jobs harder, but the ease of their job has no bearing on patient comfort!

To those that think I'm speaking out of turn, I offer my apologies.

[HERBIE1]

I'd like the doc's input on this, but I think I already know the answer. Would the fact that a patient received prehospital analgesia for unspecified abdominal pain change how that patient would be worked up? Wouldn't he still get a a full set of blood work, a UA, surgical consult, a CT, ultrasound, Xray, etc, as dictated by the patient's chief complaint?

In years past, who had the biggest complaint about prehospital pain management of abdominal issues- the ER doc, or the surgeon called for the consult?

[1EMT-P]

As Paramedics we have a legal & moral obligation to assess & treat our patients... If a patient has pain, then we must assess & address it... As long as you document your history, physical & treatment & follow your protocols you should be fine...

[HERBIE1]

That's exactly why most of the basics I work around will not call for any sort of ALS upgrade. I'm sure it's hard to hear a medic tear you apart because you felt their services would be necessary and were rude enough to drag them away from their movie, nap, or internet time. How dare you presume to think they should do their job. I took a job with a company that was transitioning from BLS to ALS a few months ago. It's the lazy medics they've had to deal with that are making my transition so difficult. I tell these guys over and over to call me if the need me. I tell them I don't mind coming out and taking a call if they are the slightest bit unsure about anything. I also tell them to call me when they know they have a patient that needs pain medication. Most of the basics here are so used to splinting in place and listening to the patient scream all the way to the ER. They're simply afraid to call a medic here because they will more often then not berate them for calling and proceed to provide no additional care. I don't really care how burned out someone is either. If they're burned out and crusty, they need to go find a nice janitorial or food services job somewhere.

If you know you have the ability to make a patient more comfortable, you should be doing it. It's about the best interest and best treatment for the patient, period.

This is a pet peeve of mine. If a BLS crew is calling for an upgrade to ALS, then clearly they are not comfortable with the patient. If it turns out after the ALS crew evaluates the patient that ALS care is truly not needed, then this is a teaching moment. Explain what is going on, ask why the crew was uncomfortable, and address their concerns. We all had to learn sometime, and nothing changes unless you take the time to teach. If the BLS crew isn't interested in learning, well that's another story, but in my experience, that is rare.

Many times, a BLS crew is less experienced than their ALS counterparts, but even if they are veterans, they know less pathophysiology, have less training, and certainly have fewer options should the patient's condition deteriorate.

Any ALS crew that berates a basic for calling for an upgrade needs at least an attitude adjustment, if not reeducation themselves.

Think about when you were brand new- ALS or BLS- and were presented with a patient who's S&'S's were nothing like you were taught in the books. Not a pleasant situation to be in.

[ERDoc]

I'd like the doc's input on this, but I think I already know the answer. Would the fact that a patient received prehospital analgesia for unspecified abdominal pain change how that patient would be worked up? Wouldn't he still get a a full set of blood work, a UA, surgical consult, a CT, ultrasound, Xray, etc, as dictated by the patient's chief complaint?

In years past, who had the biggest complaint about prehospital pain management of abdominal issues- the ER doc, or the surgeon called for the consult?

It's not likely to change the workup. It may actually help us focus our workup. If you have someone with an appy, they can develop diffuse abd pain. If you give morphine/dilaudid you will help their pain but it will still hurt if you push on the inflammed organ. Think of it like this. Most of us have broken a bone or sprained something. They can be quite painful. Give some morphine and the pain goes away. Now push on that broken bone and it will hurt. You have taken away the pain but not the tenderness. Just as an aside, with all of the technology available we don't really call surgical consults anymore. We call them when we have a diagnosis and they need to have surgery. We humor the surgeons to let them think we are consulting them (Those g--damned ER doctors don't tell us how to do our jobs) but we only call them when we know the pt needs surgery. This whole analgesia issue isn't a new phenomenon. I know when I started my rotations in 2001 this was standard of care to treat the pain.

[HERBIE1]

It's not likely to change the workup. It may actually help us focus our workup. If you have someone with an appy, they can develop diffuse abd pain. If you give morphine/dilaudid you will help their pain but it will still hurt if you push on the inflammed organ. Think of it like this. Most of us have broken a bone or sprained something. They can be quite painful. Give some morphine and the pain goes away. Now push on that broken bone and it will hurt. You have taken away the pain but not the tenderness. Just as an aside, with all of the technology available we don't really call surgical consults anymore. We call them when we have a diagnosis and they need to have surgery. We humor the surgeons to let them think we are consulting them (Those g--damned ER doctors don't tell us how to do our jobs) but we only call them when we know the pt needs surgery. This whole analgesia issue isn't a new phenomenon. I know when I started my rotations in 2001 this was standard of care to treat the pain.

That's what I thought about pain management. Thanks. Too bad so many areas still adhere to the old school ideas- mine certainly does.

It's funny, one of the first things nurses ask these days- regardless of the chief complaint- "Are you in any pain", and then ask them to rate it. Clearly it has become a priority in an ER, but has not translated yet to the prehospital setting.

As for consults, I've been out of ER's for about 10 years now, but even back then, the consult always seemed to be a formality. Then again, don't the residents need to come down anyway to evaluate if you are admitting them to their service or under their attending? Maybe it depends on the particular hospital. Then again, I worked in a busy Level 1 Trauma center so it seemed every time you turned around, there were docs of all flavors standing there. LOL

[Aussieaid]

It's certainly encouraging to see so many people advocating for adequate pain management in the prehospital setting. Rarely in our QA process are we "dinged" for giving too much pain medication but we are quickly informed if we haven't given enough. It is also encouraged to give it IM if you are having trouble obtaining an IV or it is taking a while to get one.

I like to give a dose before we even transport the patient to the helicopter and I will usually give a dose or encourage the patient to accept pain medication just before we unload them out of the aircraft and into the ER. I know that there are going to be bumps with the multiple movements involved and then when they turn the pt and are completing their assessments in the ER.

The only time I am really cautious about giving narcotics is if the patient is in extremis and I know their BP won't tolerate even a small dose. It helps to think that at least if they are at that point they probably aren't feeling a lot of the pain anyway. Better alive and in some pain then totally losing their BP. In these circumstances sometimes the few catecholamines they have floating around are all that is keeping them alive and if you take them away with narcotics they just crump and die.

As has already been mentioned, Dr's should not be basing treatments on their physical assessments alone and this includes abdominal pain and head injuries (the diagnoses most often undertreated for fear of interfering with accurate diagnosis). If they are suspecting a fracture or an injury they are going to do additional x-rays, scans and lab tests anyway. And a patient's perception of pain is totally individual and quite often not that reliable to diagnose major injuries. I have had pt's with multiple fractures/major injuries who look atraumatic say that they have no pain or very little pain. Then you get the patients with 10/10 pain who end up having nothing at all wrong with them except minor aches and pains. I always take into consideration the verbal and the non-verbal cues and always take at face value what the pt states the pain is. We had a lady with a pelvic fracture among other injuries who said her pain was severe but she didn't receive much pain meds because the provider thought she was too calm (lying there quietly with her eyes closed) and didn't think she was really in pain.

Here is an article written by a nurse on the physiological response of pain. One main point I think is that pain causes increased oxygen consumption and in sick and traumatized pts we really need to be minimizing this.

I enjoyed all the other articles posted and found the Dr BledsoeJEMS one very useful for teaching purposes. Thank you all for a great discussion.

[spenac]

Thanks guys for giving me ideas on how to deal with the situation with the nurses. So far none of the ER doctors have personally said anything. But they usually don't as our Medical director is their boss as well. I'll print those articles out and be ready to help educate.

[tniuqs]

This nurse obviously has no idea what she is talking about. The literature shows that giving pain medication does not interfere with the exam, in fact it has been shown to improve the accuracy of the exam. Even if you are in the hospital bay, give pain meds. In the time it takes for the pt to get into the hospital, onto the hospital strecher, triaged, wallet biopsied, etc, more meds will have had time to work. I'd recommend keeping a file of studies on the ambulance to show to hospital staff that have no idea what they are talking about. Here are a few to get you started.

http://www.ncbi.nlm.nih.gov/pubmed/17636812?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=3&log$=relatedreviews&logdbfrom=pubmed

http://www.ncbi.nlm.nih.gov/pubmed/17032990?ordinalpos=11&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1070812

Hey thanks ERDoc and Aussieaid ... added to my files, and thank god I don't have to patch to use narcs .. and that so sucks HERBIE1 !

wallet biopsied tee hee.