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

[zippyRN]

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.

sounds like a perfectly reasonable course of action as well as establishing what regular meds the patient is scripted, if they are scripted any PRN meds and finding out when they last took them.

and further to my last post discussing Entonox - a link to the BOC safety data sheet and summary of product characteristics

http://www.bocsds.com/uk/sds/medical/entonox.pdf

[Bieber]

I happily give pain medications out to any patient that falls into my protocols allowing me to give pain control and who I truly believe to be in pain. I try to always err on the side of caution and giving pain control, but I'm also a little hesitant to do so if my patients are able to hold a conversation with me no problem, throw a big fuss about the IV stick, or don't present in a way that is consistent with someone who is in pain. I'm also still just an intern, so it's not entirely under my control, but when I'm practicing on my own it will be and I hope to always err on the side of pain control. I'm not out to catch drug-seekers, but I'm also not completely blind is what I'm saying.

Do I think basics (or even intermediates) should be giving pain control, or even performing other paramedic level interventions? Sorry, but no. It's nothing against basics or intermediates, because I'm currently an intermediate myself, it's just a matter of the level of knowledge and experience. And I'll put it this way, I've been through basic, intermediate, and now paramedic school, and though I am new to this maybe that's a good thing in this instance, because I still see just how hard it is to be a competent paramedic and I still struggle every day at work to try and meet that expectation, and with all of my education it is still very, very difficult for me. And there's a lot of EMT's out there with way more experience than me, but even so, I've been through paramedic school and I've had to sit through months and months of lectures and labs to try and learn how, why and when to give the medications and do the procedures we do and I still pause before every intervention and question myself before I do it. So while I respect EMT's and everything that they do, I don't think that a weekend class or even a week or two of classes can make them ready or ought to allow them to do the things that, after months of training, I'm still nervous to do. And this isn't to say that an especially talented person couldn't, but rather just to give an idea of how much education it takes to competently provide paramedic level care. It's just not something you can learn in a week's time. And to be honest, I really think paramedic school out to be a four year (or at least three year) program. Where I am it's a two year degree, and I still think we need more time--especially in internship.

[zippyRN]

We seem to be going round and round in circles and focussing solely on IV opiates with the usual diversion into drug seeking behaviour being the reason why EMS providers should not be providing analgesia ...

any IV or IM analgesia whether opiate or not is outwith the scope of basic level providers, this doesn't mean that they shouldn't have suitable clinical guidelines and resources to give other analgesia.

I would ask that people read the resources I've posted about Entonox and we can have a sensible discussion about that ...

If you want a discussion about drug seekers start another another thread

[tniuqs]

We seem to be going round and round in circles and focussing solely on IV opiates with the usual diversion into drug seeking behaviour being the reason why EMS providers should not be providing analgesia ... any IV or IM analgesia whether opiate or not is outwith the scope of basic level providers, this doesn't mean that they shouldn't have suitable clinical guidelines and resources to give other analgesia. I would ask that people read the resources I've posted about Entonox and we can have a sensible discussion about that ...

If you want a discussion about drug seekers start another another thread

[HERBIE1]

We seem to be going round and round in circles and focussing solely on IV opiates with the usual diversion into drug seeking behaviour being the reason why EMS providers should not be providing analgesia ...

any IV or IM analgesia whether opiate or not is outwith the scope of basic level providers, this doesn't mean that they shouldn't have suitable clinical guidelines and resources to give other analgesia.

I would ask that people read the resources I've posted about Entonox and we can have a sensible discussion about that ...

If you want a discussion about drug seekers start another another thread

Drug seeking is perfectly appropriate to include in this discussion, but certainly not the overriding issue. Whether or not someone needs analgesics is based on many factors- type of injury, pain tolerance(yes I know- a subjective idea), underlying medical conditions, vital signs, stability of patient, associated/complicating factors, etc. Besides cardiac chest pain, the vast majority of when I use an analgesic is for a serious orthopedic injury- fractures and other trauma. I've occasionally provided it(with medical control consent) to someone with kidney stones. Many places have very limited options for analgesics, and often times they are opiates or other heavy duty medications. Simply doping someone up without being able to provide a differential diagnosis is not a good idea. We have no Xray capabilities, no ultrasound, or blood tests, so I think it's reckless to simply provide pain relief with no real understanding and/or confirmation as to what the problem may be. We may aggravate and/or mask a condition and delay definitive care. Mistake, in my opinion.

[DwayneEMTP]

Awesome post Bieber! Well thought out, honest, introspective, with great explanations for your logic...Really, really good post.

I happily give pain medications out to any patient that falls into my protocols...

I've read this type of statement a few times during this thread. What kind of protocols do you mean? Other than, "A provider should give serious thought before delivering narcs to a hemodynamically unstable pt" or the like, I can't think of a pain protocol that I've worked under. I had medics at my last service claim that we were not to give narcs for abd pain, but I did, and do, and afterwards tried to find their reference, but couldn't do so. Now, understand, I have never memorized my protocols word for word but always have a good 'flavor' of what each might entail and I can't really think of a protocol that a pain patient my fall within other than those listed as indications for the drug? If they are in pain and I can mitigate that without retarding their condition then I do so...

...allowing me to give pain control and who I truly believe to be in pain. I try to always err on the side of caution and giving pain control, but I'm also a little hesitant to do so if my patients are able to hold a conversation with me no problem, throw a big fuss about the IV stick, or don't present in a way that is consistent with someone who is in pain.

I am so with you here. As in Crotchity's example, (and humor taken in the spirit intended as I wouldn't have been able to pass that up either) I would almost certainly not have given that pt narcotics as his physiological markers were calling bullshit on his verbal claims.

... I'm also still just an intern, so it's not entirely under my control, but when I'm practicing on my own it will be and I hope to always err on the side of pain control. I'm not out to catch drug-seekers, but I'm also not completely blind is what I'm saying.

Yeah man, I wish I could give you several ++++s plus a gold star for this statement.

...because I still see just how hard it is to be a competent paramedic and I still struggle every day at work to try and meet that expectation, and with all of my education it is still very, very difficult for me.

Me too brother..

...And there's a lot of EMT's out there with way more experience than me, but even so, I've been through paramedic school and I've had to sit through months and months of lectures and labs to try and learn how, why and when to give the medications and do the procedures we do and I still pause before every intervention and question myself before I do it. So while I respect EMT's and everything that they do, I don't think that a weekend class or even a week or two of classes can make them ready or ought to allow them to do the things that, after months of training, I'm still nervous to do. And this isn't to say that an especially talented person couldn't, but rather just to give an idea of how much education it takes to competently provide paramedic level care. It's just not something you can learn in a week's time.

Agreed completely. One of the reasons that many basics have a hard time understanding this is that their clinical/physiological knowledge is to shallow to be able to understand the explanations. It's difficult to explain when you can't explain that a fracture, is not a fracture, is not a fracture. It's the same mentality that says that " I don't need to know how the heart works to put on a splint!" But, well, it really helps to know how circulation works if you're going to apply a splint to a complicated fracture while trying to allow the greatest possible long term outcome. I think you've made your point perfectly, I'm just piggy backing it so that I can steal some of your glory..

I do wonder about folks saying that Nitrous should be allowed for basics based on the fact that is a relatively safe drug and self administered. I've never used it, but I can accept that it's relatively safe, the problem I have is that it may mask sysmptoms, mental/physiological that should be caught throughout an ongoing assessment. Many medics I know can't manage that on unaltered patients, I'm not sure I'm comfortable with that at the basic level. But again, I'm speaking from ignorance as I've not used it in my practice. I am curious to see what others think...

Have a great day all...

Dwayne

Edited for formatting, again. No contextual changes made. Say Admin, how many years must I be here, or how many posts are required, or what minimum Rep rating do I need before I can get an actual response to my issues over the editor and limits on numbers of quotes??

Edited November 15, 2010 by DwayneEMTP

[Happiness]

Dwaynes quote

I do wonder about folks saying that Nitrous should be allowed for basics based on the fact that is a relatively safe drug and self administered. I've never used it, but I can accept that it's relatively safe, the problem I have is that it may mask sysmptoms, mental/physiological that should be caught throughout an ongoing assessment. Many medics I know can't manage that on unaltered patients, I'm not sure I'm comfortable with that at the basic level. But again, I'm speaking from ignorance as I've not used it in my practice. I am curious to see what others think...

The nice thing about Nitrous is that once the drug is discontinued the effects of the drug are gone. If a medic feels they are masking something they stop letting the pt have it. I have used nitrous as its the only real pain control I have in my little bag of tricks, I find it is effective enough to be able to get the pt to the hospital were they can get the other drugs that they are able to offer. It was a part of my PCP program but I dont really think that it would take more that a few hrs to make medics understand the protocol that comes along with it.

Have a happy day

[Bieber]

Awesome post Bieber! Well thought out, honest, introspective, with great explanations for your logic...Really, really good post.

Thanks, Dwayne. I'm humbled by the praise of someone like yourself.

I've read this type of statement a few times during this thread. What kind of protocols do you mean? Other than, "A provider should give serious thought before delivering narcs to a hemodynamically unstable pt" or the like, I can't think of a pain protocol that I've worked under. I had medics at my last service claim that we were not to give narcs for abd pain, but I did, and do, and afterwards tried to find their reference, but couldn't do so. Now, understand, I have never memorized my protocols word for word but always have a good 'flavor' of what each might entail and I can't really think of a protocol that a pain patient my fall within other than those listed as indications for the drug? If they are in pain and I can mitigate that without retarding their condition then I do so...

The protocols I work under allow pain management for patients complaining of chest pain, abdominal pain, and isolated trauma with a blood pressure >90 mmHg and no mental status or respiratory impairments. Unfortunately, I work in a very much "cookbook" and "mother may I" type of service. But we just got a new medical director, so I'm hopeful for change and more independence to use our heads.

I am so with you here. As in Crotchity's example, (and humor taken in the spirit intended as I wouldn't have been able to pass that up either) I would almost certainly not have given that pt narcotics as his physiological markers were calling bullshit on his verbal claims.

Exactly. And I'm not claiming to be an expert or anything, but it seems like there is a very vast difference in the way people complaining of pain who DO have visible signs of it (in their presentation and vitals) act versus how those who don't have those physiologic changes act. I'm not saying it's a fullproof tell, but it's just one of those extra things that makes me go "Hmm..."

Yeah man, I wish I could give you several ++++s plus a gold star for this statement.

Haha, thanks.

Me too brother..

Oh great, you mean it's never going to go away? Haha.

Agreed completely. One of the reasons that many basics have a hard time understanding this is that their clinical/physiological knowledge is to shallow to be able to understand the explanations. It's difficult to explain when you can't explain that a fracture, is not a fracture, is not a fracture. It's the same mentality that says that " I don't need to know how the heart works to put on a splint!" But, well, it really helps to know how circulation works if you're going to apply a splint to a complicated fracture while trying to allow the greatest possible long term outcome. I think you've made your point perfectly, I'm just piggy backing it so that I can steal some of your glory..

I do wonder about folks saying that Nitrous should be allowed for basics based on the fact that is a relatively safe drug and self administered. I've never used it, but I can accept that it's relatively safe, the problem I have is that it may mask sysmptoms, mental/physiological that should be caught throughout an ongoing assessment. Many medics I know can't manage that on unaltered patients, I'm not sure I'm comfortable with that at the basic level. But again, I'm speaking from ignorance as I've not used it in my practice. I am curious to see what others think...

Never got to play with it, I'm afraid. Well, except at the dentist's office. My service used to use it a long time ago, but they got rid of it when people were showing up at the hospitals with empty tanks after only transporting one patient for the day so far... Haha. So I can't attest to its effects or safety, really.

[HERBIE1]

The only experience I had with nitrous is years ago working in an ER. Really no fear of overdosing- usually it was self administered by the patient. They would be forced to hold the mask themselves, and by the time they were sedated enough, they no longer had the strength/control to hold the mask anymore, and they would simply drop it. The procedure would be completed and they would soon wake up.

[Just Plain Ruff]

It is not my responsibility to determine if someone is a drug seeker or not. I don't have a degree in psychology or sociology so I can't say for certain that they are a drug seeker.

If the patient has pain, they get pain relief. We have liberal standing orders for pain relief. I use those liberal standing orders on all patients. If they say they are in pain, they get pain meds because I know that a ride in the back of an ambulance is going to intensify the pain.

For fractures or traumatic injuries they get fentanyl. For chest pain they get Morphine

For abdominal pain I'm going to call medical control but our docs are pretty good about giving pain meds to abdominal pain patients as it's come out in thep ast couple of years that EMS administration of pain meds does not truly mask the symptoms of abdominal pain for a good Surgeon.

The worst feeling I have is a patient I know needs pain meds for abdominal pain and the doctor refuses to give orders for pain relief. That makes me, as dwayne says "batshit crazy". Kidney stone pain is another one that docs routinely refuse pain meds.

Seriously, if there is pain, why not give meds? Does it take away from you as a person or medic?

I transported a woman from a small hospital to a pain clinic 45 miles away over a very very bumpy 2 lane highway. NO pain meds were given to this patient prior to leaving the hospital. No IV either. 10 minutes out of the hospital she begins to complain of significant pain, crying and tearing up. I tried to call the ER via cell with no signal, radio in the truck was broke.

I went on our standing orders and started the IV, gave zofran for her active nausea/vomiting and administered 50mcg of fentanyl. Made the drive much nicer.

On arrival at the pain clinic the doctor refused to examine her because she had pain meds. The doctor said that she has a "rule" of No pain meds prior to the appointment. I told her it was a stupid rule and it was inhumae to make this patient ride in the ambulance for 45 minutes crying in pain just becuase she didn't want to give a patient pain meds. After a discussion with my medical director over giving meds without orders, my medical director backed me and said that I operated under the EMS Standing/protocol orders for pain control.

I stand by my decision. It benefitted the patient not the doctor. The doctor did finally agree to see the patient and did what she said she would do for the patient. The ride back was much better for the patient because the procedure was done and it worked.