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

[island emt]

Yes I do feel that Etonox could provide a safe reliable self limiting "non narcotic " pain relief At all levels of licensure.

Giving access to Fentanyl lollipops or transdermal patches is a completely different discussion, as you will need a means to reverse the effects of these through Narcan ,if the Pt suffers from a reaction of overdose type syndrome. Basics should not have this in their scope. Intermediates Maybe, under certain circumstances, ie very rural with long distance transport times along with the appropriate education and training to back up the skill. I;m not talking about a week long class here, more like a semester of Pharmacology and Pathophysiology to give an appropriate knowledge base to fully understand the reasons to give or not give a medication after developing a proper differential diagnosis.

There are some areas that will never have a Paramedic on every truck or even access to an intercept with one. Unfortunately many of these locations are where the crews have the longest amount of time spent in the back with their Patients.

[Fox800]

We used Entonox at a prior job of mine, with pretty good success. You can't really overdo it, when the pt. is good and lit up, they will no longer be able to make a seal with the mask. When used in conjunction with fentanyl (for paramedic providers), we had some pretty awesome results. I miss having it.

[zippyRN]

I'm glad to see that the thread is back on the right track,and not diverging off into a discussion on drug seeking.

I'm glad to see the support for Entonox from those who have used it or seen it used in other practice settings... I'm not sure exactly how long we've been using it in ambulance practice in the UK but i'm sure it's 30+ years and the original work / trials / research was near enough 50 years ago in obstetrics.

I'm interested by those who are concerned about analgesia 'masking' symptoms - unless you are overdosing someone signs are still easily elicited and analgesia may actually help to localise the site of pain - i .e it only hurts when you get to the bit which is tender / guarded rather than the anticipation of pain and voluntary guarding getting in the way of the clinical examination.

Transdermal using current techniques and devices is a bit of a no-go for EMS or acute pain in general as the current transdermal patches are designed for steady release over long periods of time - the largest fentanyl patch we get in the UK is 100 mcg/hr, getting an adequate plasma level for acute pain management with these devices is probably not viable. it's also a Schedule 2 Cntrolled Drug in the Uk ...

the fentanyl lollipops are an option but it is still a schedule 2 Controlled drug in the UK and I suspect it will be in the equivalent classifications around the world which makes it's use without specific legal mechanisms being enacted problematic, there is also the issue of reversibility or otherwise and having to carry narcan - It is also outside the licence terms at the present time so would require the clinical testing etc that expanding the licenced indication needs.

http://www.netdoctor.co.uk/medicines/100004492.html

[TJZ]

I would argue that there is training for the EMT that wants to administer pain meds... medic school or higher I think that paramedic is needed to give out narcs.

I had one partner that would not relieve head pain... he said that all it did was mask, we "debated" this often

I am in favor of medicating all that show need. We did many home to Hospice inpatient transfers and we made it policy to medicate then move.

I have only denied one patient. She was claiming 10 of 10 low back pain but was sitting outside on her concrete stoop, had no issue standing to greet us when we arrived, was talkative and walked to the rig. Oh yeah and was wearing a tank top at 2am in Dec in WI.

We were right on that one too She was a known seeker that had been to two of the area hospital just that afternoon and evening. She had the words right to get the meds but the actions were way off lol

[DwayneEMTP]

...I'm interested by those who are concerned about analgesia 'masking' symptoms - unless you are overdosing someone signs are still easily elicited and analgesia may actually help to localise the site of pain - i .e it only hurts when you get to the bit which is tender / guarded rather than the anticipation of pain and voluntary guarding getting in the way of the clinical examination.

Do you not consider mentation in the medical and/or trauma pt to be an important physiological marker then? I've often been warned early on that a pts status was changing base on the fact that they've begun to get anxious where they were not before, or the reverse, or have become suddenly or slowly quiet, have begun using nonsensical words or slurring their speech. Does this drug not mask those symptoms or is it your contention then that they are still just as reliable only subdued?

It's long been understood that proper pain management often changes the level of pain but not the location or quality, but physical pain is not our only concern when deciding who, when and why analgesics should be employed.

Traumatic scenarios are not the only that should be considered when deciding who should be allowed to to deliver these interventions. Comorbidities must also be considered, and that type of anatomical/physiological understanding will not be obtained in a weekend class in my opinion.

Narcotics can absolutely help to overcome guarding in a patient that is in pain. But unless you have some idea what that assessment is for, and what benefit you can provide for having discovered it, then the Basic argument is the same, as well as it should be for medics in this case.

Dwayne

[croaker260]

For the sake of Brevity, I am going to repost my comments on this topic from another EMS forum:

Two sides of this:

1) Pain management is at my service a BIG part of the care we provide and has been for many years. In fact, I gave more morphine in my first MONTH at my current service than I gave in three years working 2 FT and 1 PT gig in the Tennessee area. So approach to pain is definitely a regional thing. We use both Benzos and Opioids in out pain management protocols, and often together.

2) Pain management is not only a Paramedic priority, but an EMT-B one as well. Ice, distraction, positioning, and coaching breathing patterns are all EMT B skills.

I have added emphasis on the important part there, Pain Management is BOTH BLS aand ALS. BLS providers should not "wait until the medics get here" to begin to provide some relief...and and ALS providers should use both BLS and ALS interventions to control the pain once they get there.

As one other poster mentioned, I probably use pain management interventions DAILY. It does deserve more discussion in initial and ongoing education.

[zippyRN]

I would argue that there is training for the EMT that wants to administer pain meds... medic school or higher I think that paramedic is needed to give out narcs.

analgesia =/= Opiates or that horrible term 'narcs'

Opiate analgesia has a place in the Health Professional Providers' scope, i don't think anyone has denied this in this thread, although the mindsets of some groups of providers are are differing, but given the training, (lack of ) education , legal and medical direction shambles that is US pre-hospital care that's unsuprising.

elsewhere in the world first aiders and first responders as well as technician level Ambulance staff have access to a variety of analgesia medications, the principle considerations here are simple oral analgesia such as Paracetamol(Acetaminophen), NSAIDs or oral 'weak' Opioids such as codeine or tramadol. In addition there is the option of inhaled analgesia such as nitrous oxide / oxygen mixes (entonox) or methoxyflurane please see my previous posts in the thread for a variety of resources on the topic of inhaled analgesia.

[DwayneEMTP]

analgesia =/= Opiates or that horrible term 'narcs'

Opiate analgesia has a place in the Health Professional Providers' scope, i don't think anyone has denied this in this thread, although the mindsets of some groups of providers are are differing, but given the training, (lack of ) education , legal and medical direction shambles that is US pre-hospital care that's unsuprising.

elsewhere in the world first aiders and first responders as well as technician level Ambulance staff have access to a variety of analgesia medications, the principle considerations here are simple oral analgesia such as Paracetamol(Acetaminophen), NSAIDs or oral 'weak' Opioids such as codeine or tramadol. In addition there is the option of inhaled analgesia such as nitrous oxide / oxygen mixes (entonox) or methoxyflurane please see my previous posts in the thread for a variety of resources on the topic of inhaled analgesia.

A few points...

First, I'm uncertain why you quoted TJZ and then failed to address any part of his quoted text, at least that I can see.

Second, why is it when providers from other countries criticize American prehospital training/education they often do so with 4th grade grammar, punctuation and capitalization?

And lastly, did you find my questions on retarded mentation in pain managed patients to be below the level of this conversation or were just not interested in contrary points of view?

Dwayne

[zippyRN]

A few points...

First, I'm uncertain why you quoted TJZ and then failed to address any part of his quoted text, at least that I can see.

my point there analgesia =/= ( does not equal) opiates or 'narcs' there's plenty of non opiate options , this has been part of the way in which I've been encouraging this discussion to go and by and large people have taken this message on board, with the discussion or non injectable routes and with the pretty extensive discussion we've had about Entonox, including positive reports from those who have only 'seen ' it being used.

Second, why is it when providers from other countries criticize American prehospital training/education they often do so with 4th grade grammar, punctuation and capitalization?

in before Godwin , calm down Dwayne please , grammar fascism has it's place and that's in learned work and in important business work rather than in the reasonably informal setting of a forum.

And lastly, did you find my questions on retarded mentation in pain managed patients to be below the level of this conversation or were just not interested in contrary points of view?

Personally, based on a decade + of clinical practice as either A Student HCP or as an RN I feel this is an issue which is sometimes over emphasised, especially with appropriate dosing and titration, and in terms of the options we've discussed especially regarding none opiate or 'weak' opiate options is very rarely an issue.

Injudicious use of strong opiates can cause altered levels of consciousness, hence the reasons many posters in this thread feel that restricting Opiate administration to Paramedics and other Health Professionals with a field role.

Entonox can cause altered levels of consciousness, but as both myself and other posters have remarked the nature of demand valve administration and the rapid offset tend to make this self limiting.

There is also the issues around education and preparation for practice to address such concerns of providers of all levels which ties back in with the issues surrounding preparation for practice in general and ensuring that people have an appreciation of the reason for cautions and contra indications for various options and emphasising the role of the pharmacological options as part of a whole picture of patient care, where other parts of effective patient and pain management are just as important i.e. splintage , psychological care ...

[Just Plain Ruff]

For the sake of Brevity, I am going to repost my comments on this topic from another EMS forum:

I have added emphasis on the important part there, Pain Management is BOTH BLS aand ALS. BLS providers should not "wait until the medics get here" to begin to provide some relief...and and ALS providers should use both BLS and ALS interventions to control the pain once they get there.

As one other poster mentioned, I probably use pain management interventions DAILY. It does deserve more discussion in initial and ongoing education.

Croaker, I agree with you on the BLS methods.

Often we have a fractured wrist or ankle come into the ED. they ahve been moving that arm or leg for a while and no stability or splinting have been applied. Nor ice either.

many times, once ice, elevation and splinting has taken place the level of pain will drop dramatically.

Do not underestimate the value of BLS measures to relieve pain.

Same with burns, stop the burning process, cover with dry sterile dressings and the pain will sometimes (not always) decrease to a manageable level that you can continue your assessment and treatment.

BLS its not just for transport ya know!!!!