Should you withhold Pain Meds if close to hospital?

[tniuqs]

I treat the patients based on whats going on (s/s's). We have numerous choices so I can choose based on time to definitive care which may not be my hospital, type of injury, illness, etc. I use versed or other for sedation in combination with one of the choices of paralytics, based on patient event, HX, etc.

What types of patients? Race plays no part. Their past medical HX does play a part and while I know certain illnesses happen more in certain races I never presume that just because they are a race they have that problem as it could cause me to miss the actual problem.

As to drug seekers. Not my job to decide who is faking.

I don't push enough narcotics to worry about being considered a user, as mentioned earlier we are rural and most of you guys push more in a week than my entire service does in a month probably. Plus as far as Pee test I used to think my name was random.

An excellent reply to foolish questions.

cheers

[armymedic571]

You guys are spot on........ As long as the intrevention does not delay the actual transport. Time to the ED does not matter. Most of the Nurses, and such that I have encountered that seem to mind, are burned out, and/or undereducated. It is a shame, but it is time for them to find a new profession.

Cheers.....

AM571

[kevkei]

One question I would ask is - for your area, when does transfer of care occur? At triage or when you off load your patient to a bed and give a report?

For me here, point of care transfer doesn't occur until I give a verbal report and 'transfer care', which I typically purposely don't do until I've done all I want to do, including a top up if needed. Unless a Physician is present, I won't ask for their input as the patient is still technically in my care. If present, I'll ask for their support and have yet to be declined. So I guess I'll treat long after arriving at a hospital

My philosophy is to treat my patients the way I would want to be treated if in their shoes.

Does this said nurse have a position of power or authority over you? If not, don't waste your time. Typically when questioned, I will ask if their intent is to honestly find out or are they questioning my treatment. If they are questioning me, why would I need to justify my actions to them? Since I am already wrong in their eyes, what's the point of trying to change their attitude, bias and perception?

I think you were completely correct in what you did and agree with your thought process. You did the right thing, for the right reason. Don't ever change that nor question yourself.

[crotchitymedic1986]

I didnt mention anything concerning race, I was just pointing out that sickle cell/migraine/drug seekers are complaining of "PAIN". If we are all about relieving pain, shouldn't we relieve their pain too ?

[fireflymedic]

I didnt mention anything concerning race, I was just pointing out that sickle cell/migraine/drug seekers are complaining of "PAIN". If we are all about relieving pain, shouldn't we relieve their pain too ?

I am in agreement there - pain should be relieved. I tend to lean towards toradol for migraines. I have not had a patient with sickle cell crisis yet, but after reading how painful it can be, I imagine I would be more than willing to administer at least some analgesia. When considering whether to give analgesia, I keep in mind that pain is a subjective thing and what may be intense for one person, would be minor for another. Yes our service in particular does come across a significant amount drug seekers as we are a rural area with very little to do (and a known drug pathway as well, however as others have stated, it's not my job to judge them but I'm not going to feed their addiction either. And for certain things, toradol (a non narcotic) actually works better than narcotics (kidney stones in particular). There are indicators of pain besides whether a patient is crying in pain or not - vital signs is a good one.

Along the same lines though - we are also responsible for trying to ease our patient's emotional pain as well. This is something harder to do and requires time and compassion but we are just as responsible for doing what we can to ease that as we are their physical pain. Taking 5 minutes to just listen to a patient and hear what they are saying (or in some cases not saying) goes a long way. Sometimes that goes farther than any narcotic ever will.

As far as when our transfer of care actually happens - it's not official until the nurse signs off on our report. We could leave them on the bed, give a full report, and still be charged with abadonment if the run sheet wasn't signed off by the nurse. I think this is the point most handover care, but if a nurse signs off for you at triage, then technically you transfered care then.

My point is that if you are giving Morphine for every patient that has pain, then that is a disservice to those patients. They should be treated with the appropriate drug. I say the same thing for Paragods that use Versed for RSI, it is the wrong drug for the scenario -- you should not overdose someone so that you can put in an ETT. If you are going to do RSI, use paralytics.

I am aware of this practice, and am not fond of it. I even know of two flight services which utilize it and it still makes me go what! when I was told. It is not true RSI and should not be stated as such - in this case most places refer to it as PAI (pharmaceutical assisted intubation). I am in agreement - proper drug should be utilized for the situation.

Edited October 21, 2009 by fireflymedic

[Arctickat]

Nothing drives me battier than to be called to our local hospital to transport a 200 pound 55 year old male who is having an active MI and 9/10 chest pain to the cath lab only to discover that the "pain management" consisted of 2 or 3mg of morphine. First thing I do for the poor guy once he is settled into the ambulance is do drop in 5mg and usually another 5mg 10 minutes later...then another 5mg until that pain is under control. I really don't understand what the issue is that some people have with pain control for the patient.

Oh, and we don't need pee tests any more...they have saliva tests for that now.

Edited October 21, 2009 by Arctickat

[tniuqs]

I didnt mention anything concerning race, I was just pointing out that sickle cell/migraine/drug seekers are complaining of "PAIN". If we are all about relieving pain, shouldn't we relieve their pain too ?

http://www.jems.com/news_and_articles/columns/Wesley/battle_of_the_sexes.html

[tniuqs]

One question I would ask is - for your area, when does transfer of care occur? At triage or when you off load your patient to a bed and give a report?

For me here, point of care transfer doesn't occur until I give a verbal report and 'transfer care', which I typically purposely don't do until I've done all I want to do, including a top up if needed. Unless a Physician is present, I won't ask for their input as the patient is still technically in my care. If present, I'll ask for their support and have yet to be declined. So I guess I'll treat long after arriving at a hospital

My philosophy is to treat my patients the way I would want to be treated if in their shoes.

Does this said nurse have a position of power or authority over you? If not, don't waste your time. Typically when questioned, I will ask if their intent is to honestly find out or are they questioning my treatment. If they are questioning me, why would I need to justify my actions to them? Since I am already wrong in their eyes, what's the point of trying to change their attitude, bias and perception?

I think you were completely correct in what you did and agree with your thought process. You did the right thing, for the right reason. Don't ever change that nor question yourself.

Although I must agree kevkie, in todays "Hit the Wall" this philosophy can be very challenging to actually implement, point in fact my comment prior (grizzly bear attack) my issue was in the QE 2, in passing in my personal opinion (and McLean's magazine) one of the worse facilities in Canada. Even on a wait and evaluation and then 90% return rate to sending rural facility, the flight crews were expected to babysit the patients in the halls ... now when push came to shove and a meeting was held with AHC the direction was that we could monitor drips but not give IV meds.

Quite the blank stare when I asked "So if the patient arrests just who is responsible to work the Code" ... well the hospital was responsible, oh and I have not been invited back to further discussions either.

Some facilities, and especially with the idealistic Lieperts pipe dream (er blow smoke up asses) that Paramedics work in rural facilities as Primary care providers, flashback well in those days direction from AHC was very clear once past the threshold of the door to ER the facility became responsible for ALL care.

Your mileage may vary

[crotchitymedic1986]

LET THE RECORD BE CLEAR THAT IT WAS NOT I WHO INTRODUCED RACE INTO THIS TOPIC, but that was an interesting article tniugs. As far as "when" does the patient become a hospital patient, it was changed by EMTALA / JCAHO to include up to 75 feet off of the edge of the hospital's property, after someone who tried to ambulate to the hospital collapsed and died at the edge of the property, and the ER staff refused to go get him (thats the urban legend anyway). Once the patient enters that perimeter, regardless of how they got there, they have "came to that hospital seeking help", have become the responsibility of the hospital, and must be provided their medical screening exam (in the US).

As to who is to blame for what happens if the patient arrests on your stretcher while awaiting an ER bed; you and the hospital should be in trouble -- just because you have entered the hospital's property does not mean that you should stop monitoring your patient, and the ER has a responsibility to provide atleast a timely and adequate triage for all patients, regardless of how busy they are.

[spenac]

As far as "when" does the patient become a hospital patient, it was changed by EMTALA / JCAHO to include up to 75 feet off of the edge of the hospital's property, after someone who tried to ambulate to the hospital collapsed and died at the edge of the property, and the ER staff refused to go get him (thats the urban legend anyway). Once the patient enters that perimeter, regardless of how they got there, they have "came to that hospital seeking help", have become the responsibility of the hospital, and must be provided their medical screening exam (in the US).

That has made it bad for us because helicopters can not reach us many times so we used to have them meet us at the hospital and give them to helicopter crew to take to a bigger hospital. Now we have to find landing areas elsewhere or have the band aid hospital add to the patients bill and also delaying the care they need.

I just noticed that someone has said you should with hold pain meds on both poll options. Care to explain?