Is Pain Management a High Priority in Your Approach to Patient Care

[spenac]

Someone I know (used to work with) posted a similar topic on another so called EMS site and got some interesting responses. Then today while looking at our high quality medical journal JEMS saw that it had appeared there as well and was getting discussed. http://connect.jems.com/forum/topics/is-pain-management-really-a

Both are based off the referenced report http://www.associatedcontent.com/article/5930346/is_an_ambulance_an_ambulance_the_differences.html?cat=5

Hopefully by giving you reference points I have not violated any laws.

What value do you place on pain relief of your patients? Would pain relief be a justification for a community to spend money on hiring Paramedics? Or should pain relief be another skill training/test/cert for basics?

As I have been asked on other topics I will say there is the possibility I may play devils advocate to provoke more thoughts and discussion depending on how it goes, no offense will be intended by my responses. I will save my opinions until later.

Edited November 13, 2010 by spenac

[tcripp]

Interesting post, Spenac. I am of the mindset that as long as we (in general) keep accepting the option of providing a weekend class to the Basic so that he or she can do the job of the Paramedic, communities will always take the cheap way out and medics in the industry will never earn the money they could. Of course, this also ties in to the great debate of paid vs volunteer.

To answer your questions specifically, I believe in using the tools we have to take care of our patients as needed and that includes pain management. I work in a rural area that has a high population of geriatrics where we see lots of falls. Why not relieve their pain prior to the move? Frankly, the use of an analgesic is as much for them as it is for me. The more calm calm the patient, the more calm the medic.

As one person posted, "It's rare when I am truly able to save a life. But I have the opportunity to ease someone's pain on an almost daily basis. I'm not giving it away like I was a predator with candy or anything, but I have no fear or hesitation when it comes to easing my patient's pain. If you're on my box, and are a really in pain... baby you came to the right place!"

[DwayneEMTP]

I believe that pain management is one of our most important tools, and one that is very much under used. And of course I don't believe that basics should have access to narcs/benzos.

One of the things that makes me batshit crazy is to listen to the yahoos talk about how they're able to 'spot a drug seeker' a mile away. Bullshit. I've even heard them talk about withholding pain management for their drug seekers that they truly believe are now in pain, based on the patients previous history. Man, this is one of the best reasons to increase educational standards for EMS. Perhaps is those folks have their knowledge to be proud of then they won't need to attempt to show their 'specialness' by showing how callus they are because of all of their 'experience.

I believe that my job is to provide physical, physiological, and emotional support when possible. And though I don't often share their beliefs I certainly find no need to interfere with their spiritual beliefs either and am happy to find such support for them when I can. Have I given narcotics to a known drug seeker? Probably, but often I haven't, not because I believed them to be seekers, but because the list of symptoms that they chose to give me to fulfill their needs lead me to believe that narcotics weren't prudent until after a physician level exam. Ladies and gentlemen!! Drug seeking is a symptom! Because you happen to believe that these people should not have interupted your tv show with their silly symptom doesn't mean that they deserve less professional care! Thank you for listening.

To our newer and younger providers. You will be awash in shitheads that are going to try and convince you that you haven't made your bones until you have proved that you are tough enough and experienced enough to deny proper care to those that you don't feel deserve it. Sounds crazy, I know, but most here I believe will back me up on that. Should you choose to join that club I'd ask this simple thing. Turn over the card that your certification came printed on, and in a Sharpy marker write, "This certification no longer applies to me. I have decided to become one of the wanker shitheads. I have earned the right to wear the patch, and my hero Tshirts, but I have forfeited my right to consider myself a professional medical provider." And then go on with your life.

Every patient has a right to have an ambulance come to them. Every patient has a right to a professional, thorough assessment, and every patient has a right to complete and competent treatment based on that assessment up to and including emotional support and pain management. Ok?

As often happens you may think that I'm on the fence on this issue...I'll try and be more clear in the future...

Dwayne

Edited to repair formating.

Edited November 13, 2010 by DwayneEMTP

[emtannie]

One of my frustrations as an EMT working a rural BLS service is the lack of pain medication I can provide. I feel that a medic can provide far superior care in a lot of situations that I find myself in (hence one of the reasons I am currently in paramedic school).

Do I think that basics should be able to provide more meds? No. Anyone working in the medical field should have a thorough education to know the anatomy and physiology, pathophysiology involved, and risks and benefits of the medication before giving it.

For example, not that long ago, I had a call for a 24yo male who had a leg caught in a piece of machinery.. he was in excruciating pain, and the only pain med I am allowed to give is Entonox (nitrous oxide) which really wasn’t enough in this situation. After a 15 minute extrication, and 25 minutes to hospital, this poor guy had been in pain for a long time. Since pain can increase shock, by not trying to control this guy’s pain, I am really not helping him as well as I could, since I cannot control his shock well either. ALS was over an hour away, so my only hope for pain control was to get him to the hospital.

Did I do as much as I could for that patient? Absolutely, as I did all I could within my scope of practice. Was it enough? Absolutely not. I am not advocating handing out pain meds like a Pez dispenser. I am advocating providing pain medication as part of a thorough treatment, after a thorough assessment and history is obtained.

Pain control is as much a part of patient care as holding a hand, or consoling a patient, or providing airway management or fluid resuscitation. It is part of what we should be doing. Dwayne said it so well when he said “Every patient has a right to have an ambulance come to them. Every patient has a right to a professional, thorough assessment, and every patient has a right to complete and competent treatment based on that assessment up to and including emotional support and pain management.”

[Happiness]

Ok I did the vote before I responded and I have to say I'm probably not the norm.

I think pain controll is very important in pt care, but I dont nessacaraly think it has to be all the narcotic drugs. The only protocol in pain I have is 02(nitro in cardiac), nitrous oxide and a teddy bear.

I think demographics are very important also as most of my calls are no more than 1/2 hr away.

I have two stories of pain

17yr old male dirt biking on the beach hits a rock funny and breaks his femur. I get there 10 mins after and start my protocols. I have all my great fireman to help me. We start by stableizing the break with blankets and zap straps (i luv those straps) in position found he had good peddles. He was screaming but once he felt snug like a bug in a rug he lighten up. I gave him entonox as we were doing this and for the bumpy transfer off the beach (again i luv ff), my partner (freaked)was able to drive slow to the hospital which was 3 min away but we took about 10. Now if this had happened out the road at a different beach I would luv the ability to give other drugs.

Now the teddy bear you might ask, many years ago I had the pleasure of learning from a pt the advantage of hugging a pillow for abdominal pain. I have no idea why this works but it does and on my shift if the pt has this pain I offer them a teddy bear to hug and to my surprise it works for them. Maybe its just the fact of hugging a bear that makes them feel better or it's some physiological aspect.

Anyways thats my cent worth

happy

[zippyRN]

while i voted for yes a weekend class for basics to administer pain relief it would not be for paramedic levle drugs , just what the rest of the world has at First Responder / EMT / Tech level i.e. entonox ( premixed nitrous oxide + oxygen via demand valve ) and paracetamol - the aussies have methoxyflurane but that's not a licensed drug outside aus due to the side effect profile when it was used in anaesthesia

while wikipedia may not be a sufficiently learned source for some it sufficies for this kind of informal discussion

http://en.wikipedia.org/wiki/Methoxyflurane

http://en.wikipedia.org/wiki/Entonox

http://www.entonox.co.uk/en/discover_enotonox/story_and_heritage/index.shtml

http://www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/prehospitalcare/jrcalcstakeholderwebsite/a-z/drug/entonox/

Entonox has been used in clinical practice in the Uk for nearly 50 years and there's decades of experience with first aiders / first responders and emt / tech level providers using it. Entonox does work but the patient has to be be encouraged to take it appropriately - taking if at or after a painful move etc is not the optimum - they should be loaded up and then you move etc.

I've also seen plenty of anterior shoulder and some knee/ankle dislocations go back with entonox alone ... and i've reduced a circulation critical ( and therefore limb threatening)lower leg / ankle fracture under entonox before with good results

Edited November 13, 2010 by zippyRN

[island emt]

Pain relief is probably the single greatest thing we can provide for our customers. The only way we have to provide pharmaceutical relief is for a Paramedic to administer Fentynal.

Basics and Intermediates have Oxygen , immobilization and ice packs only.

I feel that basics and Intermediates can be educated in the proper administration of etonex which is essentially self administered by the patient and has a low risk versus benefit for the Pt.

[Eydawn]

Ladies and gentlemen!! Drug seeking is a symptom! Because you happen to believe that these people should not have interrupted your TV show with their silly symptom doesn't mean that they deserve less professional care! Thank you for listening.

You hit the nail on the head here, Dwayne. Drug seeking, attention seeking through parasuicide attempts, cutting... all of these are SYMPTOMS OF A PROBLEM. Just because you cannot effect a CURE in the short time you have them with you doesn't mean that you can't do anything for them...

Wendy

CO EMT-B

[crotchitymedic1986]

Well obviously this is a racist issue as well, since sickle cell patients rarely get pain relief versus the rich white woman with the supposed migraine. JUST KIDDING, COULDN"T HELP BUT TAKE THE CHANCE TO MESS WITH ALL OF YOU !

There is a double-edged sword to not "spotting drug seekers". If you continue to treat the fakers, they will call you more often, as they will get better meds from you than they will from the ER. I can envision some of my old frequent callers, calling several times per day instead of several times per week, if they knew I would give them the good stuff. Once the got to triage, they could walk-out, catch the bus, head home with a good buzz, call again when it wears off. You also have the issue that if you treat fakers with the same zeal that you treat real patients, it will probably not be very long before the ER Docs start screaming to change your protocols and reign you in.

I agree, that if there is any doubt, we should treat, but what about this scenario:

30 year old male with chronic back pain calls you on Saturday night for back pain that is a 10 out of 10. He is resting comfortably on his couch, B/P 110/80, Pulse 70, RR 16, warm and dry. He is allergic to Tylenol, Motrin, Toradol, and Codeine. He states his pain can only be relieved with Dilaudid or Morphine.

So how do you treat this patient, what is your medicine of choice to relieve his "pain" ?

[island emt]

30 year old male with chronic back pain calls you on Saturday night for back pain that is a 10 out of 10. He is resting comfortably on his couch, B/P 110/80, Pulse 70, RR 16, warm and dry. He is allergic to Tylenol, Motrin, Toradol, and Codeine. He states his pain can only be relieved with Dilaudid or Morphine.

So how do you treat this patient, what is your medicine of choice to relieve his "pain" ?

Since He's resting comfortably on the couch at home and is not in distress per his vitals. He would get the offer of a trip to the hospital for further evaluation.

He would not meet the criteria for pain medications per our protocols.

Chronic pain can be real and it can need treatment if the S&S are indicative of severe new onset issues.

We would more than likely offer to call his PC physician and see whether he/she would like us to transport to an ER.