Pain managment techniques within the EMT-B and paramedic scope of practice

[runswithneedles]

I completed a 5 hour trip to dallas with a patient that had a small bowel obstruction. My box carries nothing for pain to begin with and the patients demerol wore off about 1/3 of the way there. Since we are a basic crew I didnt even have a medic who could stop in the next towns ER to pick up a DR's order for pain meds. This woman was in tears the rest of the way 3 hours and 45 minutes to be exact) and the following morning was just about to bust down my managers door about to spew fire. But instead of being a thorn to my managers side I figured I would take a more constructive approach to the problem. I want to begin doing research for cost effective pain management for patients that fit the EMT's scope; what kind of paperwork/cost/licensing would be involved and each interventions effectiveness.

But since im doing the research I might as well present addtional interventions for the medic as well that are cost effective. Since ALS boxes dont carry pain management either.

Where do I begin? What would you recommend? How do I present it to give me the max possibility for it to be implemented. And who do I present this information to?

Edited April 3, 2012 by runswithneedles

[Kiwiology]

Entonox, its cheap and has been used in this part of the world (and the UK) for nye on three to four decades without major problems

We use a single cylinder with a 50/50 mix however the FDA requires you to carry a dual cylinder with a mixer / blenderiser thingomadongle

You can also look at methoxyflurane; its long since stopped being used as an anaesthetic but it is what Australian services use for their community first responders to provide at least some analgesia (remember that every ambulance in AU carries some people who can give parenteral analgesia)

[Eydawn]

What do you mean, exactly, that ALS boxes don't carry pain management? You guys just don't have any pain management protocols period? I'm so confused.

Wendy

CO EMT-B

[Happiness]

Entonox is a choice. I dont know if it a good one for 3 hrs as it displaces O2, so you have to be aware of O2 levels. This is the only pain management that I have in my tool box. Years ago a pt was medivaced home from abd surgery said that they gave her a pillow to hug. This is suppose to help take the pressure off the area. She was pretty surprised that it did work for her.

I dont understand why you would be angry at management, as it the fact that you are BLS and not able to administer the meds under your license right. If your ALS dont have pain meds in their tool box why are you going for it should it not be one of them.

Happy

[mobey]

That is exactly what I battled with for years, felt like I was cheating my patients out of proper care. So I went to Paramedic school, and changed provinces!

Entonox will be the only choice for BLS in the U.S..

Honestly though..... you may want to consider a change of scenery if your ALS providers do not even have analgesia. Change can and should be made, but it will take years, by that time you may be pretty burnt out of watching the suffering and deterioration of your patients.

As a caviet: Bowel obstruction can be verry hard to manage painwise. I just did a 4hr transfer of one a few days ago, I used Ketamine augmented with 50mcg doses of Fentanyl, as well as Gravol and Zofran, just to try keep her comfortable. She still wasn't. It hurts to not poo...... and in that case Entonox is contraindicated anyway.

[Just Plain Ruff]

First off putting a patient with the need for pain relief in a BLS ambulance for a 5 hour trip was FUCKED UP BEYOND BELIEF and if it was my mom or dad I'd be livid and pissed off. I'd be in that doctors office and the hospitals administrators office wanting to know who's head I got to mount covered in pitch tar on a spike on the peak of my roof.

There was no need for that patient to suffer for that long. If I was you I would have stopped the ambulance, called the nearest ALS ambulance and requested ALS intercept. Sorry but pain relief is a an ALS skill and that patient needed it.

Why don't you give the doctor who said it was ok to put that patient in a bls ambulance without the ability to give pain relief, a bowel obstruction, put him in an the same situation and drive him 5 hours without pain relief and see how many more of his patients he sends without pain relief. I'll bet he never sends another of his patients out without enough pain meds to snow a horse.

That's just STUPID FREAKIN MORONICITY.

I am not harping on you on this on Runs - not in the least.

This is what really pisses me off, the patient needed pain meds and didn't get them.

Now back to your regularly scheduled thread.

You first need to find out if Entonox is even a allowable skill in your state for EMT's to give. If it isn't then you are not going to be given that skill, unless the state re-writes their guidelines. OR If your medical director goes to your state bureau of EMS and begins the long arduous process of asking for an exemption of letting your crew (emt's only) give this for these types of transfers only based on additional training. I would not hold your breath on your medical director doing this extra effort. If you do hold your breath, prepare to be intubated as you will probably passout and die first.

Best thing is to just grin and bear it that you will still have dumb ass doctors who think that demerol will last for 5 hours and their patients will have enough pain meds on board for that 5 hour trip.

And rest assured that you probably won't have another transfer like this for a long time. But another patient will have to go through this again probably tomorrow or better yet, is probably going through it RIGHT now. Comforting aint it.

[runswithneedles]

What do you mean, exactly, that ALS boxes don't carry pain management? You guys just don't have any pain management protocols period? I'm so confused.

Wendy

CO EMT-B

This company's protocols have nothing for pain management.

No narcotics

No benzos

No non narcotics

no NSAIDS

just the basic bare bone TXDSH required drug list (ASA, atropine, epi 1:1000, epi 1:10,000, etc)

regardless of what kind of truck it is we dont carry anything to alleviate pain

I dont understand why you would be angry at management, as it the fact that you are BLS and not able to administer the meds under your license right. If your ALS dont have pain meds in their tool box why are you going for it should it not be one of them.

Happy

Im upset they sent me to get this lady and she needed it and the dispatcher didn't relay that info to me. And at the time I didnt know if I could turn this down and not be written up at work. The best I could do was get the transferring facility to load her up on pain medication and pray for the best. Which didnt work unfortunately

I hate being a ******* EMT-B. Capt If I had known I had that option to call for an als truck I would be too scared shitless to do so since it was my supervisor/COO (emt as well) that was driving. I wouldve had him and the CEO up my ass in a heartbeat.

That run made me look like an ass and a useless tool.

[DwayneEMTP]

You need to immediately decide if you will make every critical decision based on whether or not you will get written up.

Accepting a call that you believed was inappropriate for you because you were afraid that you would get jammed up? Major fail.

Being to 'scared shitless' to call for an intervention that you were confident was necessary? Major fail.

I'm not trying to bust your balls brother, but it's already past time that you reevaluate the reasons that you entered this business. If it's to be a 'cover your ass' provider, well, ok then, you're on the right track and will fit in with the majority of those that you work with.

If it's to be competent and do actual good for your patients, you're completely off in the ditch.

I like you here, love your posts, hope that you'll stay, but most of all hope that you can take my comments literally and in the spirit intended.

A year from now, depending on the provider that you choose to be, you will be embarrassed by the post above. How do I know? Cause I've got a million of them. Just search my early posting history here...But better to be smarter and humiliated later than continue down the wrong road because no one cared enough to tell you to turn your headlights on...

Keep the faith my friend...

Dwayne

[Chief1C]

We won't do scheduled transfers, usually for similar reasons. The last time we ran a "requested BLS transfer", the patient was dying from some sort of illness contracted by drinking spring water. They thought anyway. They met us at the door, and walked him to the ambo. The patient looked like a corpse, I don't know how he was walking. Pulse was so rapid I couldn't count it, and it was over 200 on the pulse ox. Couldn't get a BP, hadn't been eating or drinking fluids; so he was just about dehydrated to death. So.. I called for ALS. They met us, treated him, ER said to take him to the floor. So, we did. Nurses on the floor went up one side and down the other, and started back up again...for treating the patient enroute. I was just supposed to "provide a ride". I excused myself, and retrieved a little pocket size protocol book from the clip board. Went back into the room, told the nurse we aren't a stretcher van. They called an ambulance, they got an ambulance, and I did what I was supposed to do. The patient had a DNR, but it said IV fluids, etc. were okay. She kept spouting off about a DNR. I told her calmly that we didn't resuscitate him, we treated him, and tossed the protocol booklet at her. Someone else signed, and we left. I tell docs all the time in the clinical setting, that unless they want to ride along and run the show, I'm following protocols and set guidelines. "If that's a problem, write your congressman".

Edited April 3, 2012 by 1 C

[island emt]

The biggest fault here is the crappy transport company you are working for. Bad enough they sent a BLS truck for this transport, but your management doesn't have the protocols in place for your medic level trucks to have any pain medications. That is a major fault and would make me wonder how they can keep an ALS license. As I understand the current practice in Texas, they allow a service medical director to determine the scope of practice for their staff. This tells me you have a could care less medical director, and the company is only interested in their profit margin.

If I was your patient, I would be talking to an attorney.