Pain Management, Multi-Systems Trauma

[DwayneEMTP]

I think I would like to play with Ketamine a bit. If it's all Magic says it is then it sounds very appropriate for this situation.

I still maintain that a tiny dose of Fentanyl is as bad, or maybe worse than nothing when real pain is involved. Sprained ankle, a bit of road rash, minor trauma, that's ok maybe, but for any real pain, stand alone Fentanyl just hasn't shown itself to me to have any real claws. I think most services keep it at the dosages we use more for placebo than for true pain management. It makes the medics feel better regardless of it's effect on patients.

Dwayne

[chbare]

We have a bunch of anecdote going on, but not much evidence. What does the literature say about some of these issues?

[Bieber]

http://www.google.com/url?sa=t&source=web&cd=3&ved=0CDoQFjAC&url=http%3A%2F%2Fwww.denveremresearch.org%2Findex.php%3Foption%3Dcom_phocadownload%26view%3Dcategory%26id%3D38%3Ageneral%26download%3D209%3Asafety-of-prehospital-single-dose-fentanyl-in-adult-trauma-patients%26Itemid%3D8&ei=qC98TpZqppCwAoGzrEQ&usg=AFQjCNHGh4Js_dPl8ZKnK2swt1A-jTYKpg

http://www.dhmc.org/dhmc-internet-upload/file_collection/11.18.04%20-%20Pain%20Mgmt%20-%20New%20England%20Trauma%20Competition.pdf

I'll post more as I find them.

[Paramagic]

I think I would like to play with Ketamine a bit. If it's all Magic says it is then it sounds very appropriate for this situation.

I still maintain that a tiny dose of Fentanyl is as bad, or maybe worse than nothing when real pain is involved. Sprained ankle, a bit of road rash, minor trauma, that's ok maybe, but for any real pain, stand alone Fentanyl just hasn't shown itself to me to have any real claws. I think most services keep it at the dosages we use more for placebo than for true pain management. It makes the medics feel better regardless of it's effect on patients.

Dwayne

I really don't understand how some pain relief is worse than no pain relief. Can you explain how reducing pain, in a setting where immediately eliminating it is impossible, is less desirable than not treating pain at all? I'm not advocating the homeopathic doses of morphine that some services restrict their medics to, but surely some pain relief is better than none?

[Paramagic]

http://www.google.co...nK2swt1A-jTYKpg

http://www.dhmc.org/...Competition.pdf

I'll post more as I find them.

That is an excellent presentation from the DHMC Bieber, especially the first couple of slides. Thank you.

[DwayneEMTP]

I really don't understand how some pain relief is worse than no pain relief. Can you explain how reducing pain, in a setting where immediately eliminating it is impossible, is less desirable than not treating pain at all? I'm not advocating the homeopathic doses of morphine that some services restrict their medics to, but surely some pain relief is better than none?

Yeah, again as Chris says, it's anecdotal though. I've seen a lot of patients in pain. Many of them seemed to be able to focus and manage that pain to a considerable level. Not all, but most, including children, have some level of natural mental (guessing) pain management abilities.

In these patients it 'appears' to me to be not uncommon that when given low doses of anagesia that it snows them enough to interrupt their natural ability to somewhat manage their pain and their response to pain seems to become magnified when compared to what it was before 'touching' them with some pain meds.

For example, and I have no idea if this is valid or not. When Babs was giving birth to Dylan they had the little monitor doodad that measured her contractions. As the contraction would increase, along with her pain, the numbers on the monitor would climb. She had chosen to deliver naturally.

After about 10 hrs her contractions were a few mins apart, the monitor would show in the teens between contractions and would climb up to about 120-130 at their peak, at which point she was in terrible pain and would cry out. Finally she asked for "something for the pain."

I can't remember what they gave her now. It made her sleepy and she would start to doze between contractions, she had no amnesia afterwards. When she was awakened by the beginning of a contraction she was perfectly lucid and able to carry on a conversation with only a slightly distracted, dazed manner added by the meds. But what really changed was that when the monitor hit about 35-40 she would now cry out in pain and continue to do so throughout the entire contraction instead of just at it's peak as she'd done before.

It appeared to me that she was now much less able to cope with the pain than she had been before. When I asked her about it later she told me that it was a huge mistake to ask to be medication because though it did little for the pain it made it impossible for her to concentrate enough to 'deal with it' on her own.

Of course it's possible that I misunderstood what I saw 15 years ago, but I do believe that I see this same thing often with patients in significant pain. If I, for whatever reason, chose (often, but of course not always. And this has been my belief for so long that I don't have any recent patients to relate it to) to 'touch' them with Morphine or Fentanyl often they would become more agitated and appear to be in more pain than before I did so. If I'd 'smack' them (Don't try to keep up. I know these terms are way to sophisticated for the average provider) hard enough so that I can be confident that I'll create a significant effect very quickly I not only seem to miss the previously mentioned phase, but the second group 'seems' to take smaller doses than the previous.

All anecdotal, and I know that I now look to be the biggest moronic asshole on the City, but that has seemed to have been my experience and it's that experience that shaped my treatment of the patients mentioned above. So there you have it.

I have absolutely no idea what I would even begin to search for to try and validate my theories with research, but I would certainly be interested in those data.

Dwayne

[Bieber]

http://www.ncbi.nlm.nih.gov/pubmed/16029830

Paramagic, you're welcome!

Dwayne, I'm trying to find any studies that support/deny the use of titrated pain management and its effects on pain. And man, you already know, the only dumb question is the one not asked. You don't look stupid at all, you look like someone who is seeking answers, which is exactly what this forum is all about.

Also, I've found a couple of protocols supporting the use of pain management in trauma as long as the systolic BP remains =/>90 systolic. The studies and literature I've also read indicate that hypotension is an extremely rare complication of fentanyl, with bradycardia and respiratory depression being much more common.

http://www.emsworld.com/print/EMS-World/Prehospital-Pharmacology--FENTANYL/1$6016

[Paramagic]

All anecdotal, and I know that I now look to be the biggest moronic asshole on the City, but that has seemed to have been my experience and it's that experience that shaped my treatment of the patients mentioned above. So there you have it.

I have absolutely no idea what I would even begin to search for to try and validate my theories with research, but I would certainly be interested in those data.

Dwayne

Not at all, I am certainly not discounting your experience. I have not had a similar experience, so have no frame of reference for it, hence my trouble with the concept. Anecdote is not really the spawn of the devil (despite my tag line), it is, as you point out, fundamental to shaping our practice in medicine. I certainly don't think less of you, or anyone else for recounting and referring to experience. I try to use the "evidence" as much as I can, but let's face it, there is precious little of that around, so we have to practice medicine some other way.

I also appreciate a rational, civilised conversation; I think it is beneficial to all parties, thank you.

[Bieber]

Anecdote is the seed which spawns research to either confirm or deny the observations of an individual or group of individuals as being true or usually true on a universal scale. We have to recognize what it isn't, but we also have to recognize what it is: possibility that may merit further exploration into something that may or may not have already been confirmed but which nevertheless deserves more of an answer than just "maybe" or "I don't know".

Anecdote isn't scientific fact in se, but at the same time if we stopped asking questions and exploring what may or could be based on our own experiences, then we would only stifle research and further growth by limiting ourselves to only investing our energies in studying what has already been proven to be scientific fact. Science and medicine will never move forward without people who are willing to say, "This is what I experienced, but I want to know if this is an anomaly or reality and we deserve to know the answer."

[DwayneEMTP]

Thanks guys.

It's been a while since I've been involved in a thread where I thought, "Holy shit. I've been doing this, and thinking in this way for a while now...and I may in fact be off in the ditch." I'm sure there have been many threads here where that has been the case but I just didn't recognize them as I have here. What a gift it is to see that my friends an fellow providers will be kind enough and brave enough to intervene and help me be better today than yesterday.

I would be curious to see if anyone else has like experiences or if you all stumble across any research covering my perceived phenomenon.

You have made me rethink these cases, and that is awesome, but now, I truly have no idea what I would do if faced with the exact same situation again.

Though I've been, and continue to be a rabid advocate for pain management I think that I've not been as rabid as possible and it irks the shit out of me to think that others are doing a better and more compassionate job than I am...And that's even better I think. Less comfortable, but more productive.

Thanks again for participating.

Dwayne