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

[Just Plain Ruff]

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

i agree with Dwayne. I have a bunch of them also and if Dust was here, since he was here long before Dwayne was Dust would agree wholeheartedly with the assessment that some of my posts being assinine as well.

AS soon as you begin to put getting written up before patient care then you have become one of those crappy paramedics.

Here is what I mean

Had a transport. Patient had numerous spinal stress fractures due to osteoporosis. She was being transfered from our hospital to another hosiptal 3 hours away. She was given no pain relief except 1 Ultram pill prior to our leaving the hospital. The bumps in the road began to take their toll on her back and she began to start to scream out in pain. I began to attempt to call to the hospital to obtain medical orders to give pain relief and for 10 minutes was faced with no cell phone signal, our ambulance at the time had no radio antenna due to the previous crew drove too close to a tree limb and tore off the antenna.

So I assumed medical control failure and worked under protocol and started an IV and administered fentanyl under protocol/standing orders.

I did this and documented this. On arrival to the hospital where she was being transferred for the pain clinic and her procedure the doctor proceeded to accuse me of practicing without a license and reported me to my hospital administration who then reported me to my EMS Medical director. The doctor reporting me and my hospital administrator(director of nursing wanted me reported to the state for practicing medicine without a license)

I was a supported fully by my Medical director due to my DOCUMENTATION on my run report and my reputation as a medic at the service I worked for. It went no further but Had my medical director not have supported me I still would have stood by my decision to do what I did and take my lumps based on the patient needing the medication in order to provide her a comfortable ride. There was no excuse that this lady not having been given pain relief. The hospital failed this patient on their core measures and I made sure to tell them that as well.

Had I have worried about getting written up I would have made this lady suffer but I didn't.

[paramedicmike]

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

No. I'm afraid you did that all by yourself.

Now before you run off and think that I'm dumping on you *again*, think about what you've presented to us. Then reread what Dwayne posted in reply to you. Then think about what *MANY* of us have been saying to you since you first started posting here.

As much as you go out of your way to try to make me think otherwise I still think there's potential in you. You just need to do some growing up and you need to have it done by three weeks ago. This isn't to say become a cowboy and adopt a cavalier attitude. That'll hurt you just as badly. It is to say, however, that the human brain is an amazing piece of computing technology. The more you use it the more it grows. The more you use it the better you'll be. The more you use it the better off your patients will be.

Start using it.

[Asysin2leads]

I have this crazy notion that someone in acute pain is having a medical emergency which warrants the same response as any other life-threatening emergency. Just because someone isn't going to die in the next 10 minutes doesn't mean that they should be left in agonizing pain.

In other words, when the Demerol wore off, you should have treated it as any other emergency that went beyond your scope of practice. The two options there are either call ALS, or divert to the nearest emergency room. When you saw that she was in significant pain, you should have called your company, told them the situation, and then diverted either to meet an ALS unit line of sight or to follow the nearest blue hospital signs. If she went into cardiac arrest, that would be fairly obvious to you. The concept that being in agonizing pain is just as much a medical emergency (outside of a mass casualty incident) as any other is one that is tortuously being introduced to EMS. Your company probably won't like it but doing the right thing for the patient comes first.

So, in that aspect, BLS does have options for pain control. Call ALS, or divert to a hospital because your patient isn't stable enough for transport. Three hours without pain control? Not cool, man. That's Medicare comes a-knockin' type of stuff.

[DwayneEMTP]

You know Needles, it's easy at this point to think, "what a bunch of assholes! I was in a tough spot, you don't know what it was like!"

But we do man, cause we've all been there, mentored students that were there, and if the term 'major fail' hurts your feelings...it shouldn't. Stack my list of fails against your and yours will look nearly nonexistent. But if I hadn't been taught another way after those fails I would have continued to do things that I'm ashamed of. I'm sometimes ashamed here when I compare my knowledge to others, but I'm rarely anymore ashamed because I was unprofessional, immoral, unkind, or unethical. And that's really important to me.

This isn't about making you look stupid, but trying to be really, really clear about some core EMS concepts that are mushy in your mind but need to become rock solid.

And trust me..if this thread has made you feel badly...read some of my old post...you'll feel friggin' vibrant afterwards...

[paramedicmike]

... and if the term 'major fail' hurts your feelings...it shouldn't.

Well, yeah. It should. Because it was. The hope, however, is that he will take those feelings and turn that into a positive learning moment which will turn into positive action should he find himself in that position again.

[systemet]

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.

What medications are in-scope for EMTs in your region?

po ASA is unlikely to provide effective pain relief for injuries and illnesses commonly encountered in the prehospital setting. Entonox / Nitronox systems are used in some regions in BLS centers, but they're contraindicated in bowel obstruction. I don't remember what entonox costs, but I think it's fairly inexpensive. There's some cost for buying the tanks, regulator and masks, but this is probably minimal. There may be additional costs or paperwork if you're required or see it necessary to regulate storage and usage to prevent abuse.

In my opinion, either (1) this patient should have been transported ALS in the first place, or (2) an RN escort should have been provided to administer pain meds, if this is allowed in your area. There's multiple people at fault here, in no particular order:

* The sending physician for not considering the need for repeat analgesia in a patient who had already been given demerol at the sending facility.

* Your company, for accepting the transfer and sending a provider who couldn't provide analgesia.

* The individual providers on the transfer truck for accepting a patient that they were unable to manage, and then doing nothing to seek medical care when the patient's condition changed.

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.

I don't understand how you can have an ALS "box" without opiates or benzodiazepines. How do you intubate people? How do you maintain post-intubation sedation? How do you do procedural sedation for cardioversion / pacing? What are you doing if a patient starts seizing?

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?

I realise this probably doesn't come across as very helpful, but I'd consider looking for employment with a better organisation that's more committed to taking care of its patients.

I think you've made this situation more difficult by not dealing with it when it occurred. I think you need to get together with your partner and discuss how things could have been done differently in a constructive and nonjudgmental manner. This may be challenging if your partner is a supervisor. Then I would suggest submitting a proposal for some combination of (1) addition of BLS or ALS pain relief measures, and (2) a new mechanism for screening transfers and assigning the appropriate level of care, to the next tier of management and possibly the medical director, together. Recognise that this may be a career-limiting choice in this particular environment.

You have an obligation to future patients to prevent this from happening again, and you have a lesser obligation to your partner not to get them into trouble without talking to them first. Then you have a very secondary obligation to not just jump of chain of management without consulting them.

Edit: its versus it's

Edited April 4, 2012 by systemet

[island emt]

You know Needles, it's easy at this point to think, "what a bunch of assholes! I was in a tough spot, you don't know what it was like!"

But we do man, cause we've all been there, mentored students that were there, and if the term 'major fail' hurts your feelings...it shouldn't. Stack my list of fails against your and yours will look nearly nonexistent. But if I hadn't been taught another way after those fails I would have continued to do things that I'm ashamed of. I'm sometimes ashamed here when I compare my knowledge to others, but I'm rarely anymore ashamed because I was unprofessional, immoral, unkind, or unethical. And that's really important to me.

This isn't about making you look stupid, but trying to be really, really clear about some core EMS concepts that are mushy in your mind but need to become rock solid.

And trust me..if this thread has made you feel badly...read some of my old post...you'll feel friggin' vibrant afterwards...

Applaus Applause de jour Dwayne. +5 to use a dustism.

[Just Plain Ruff]

I think you need to find out first why your company's drug boxes do not carry narcotics?

There are a couple of reasons why off the top of my head that your boxes don't have narcs

1. Your medical director didn't apply for a narc license because he didn't expect that your medics would be administering narcotic analgesia

2. Your service lost it's DEA license due to some reason (nefarious or not)

3. Your service DEA license expired

4. Your service DEA license was never relicensed

5. Your service never applied at all.

6. some other reason

[Asysin2leads]

Needles, I didn't mean to bash you either. I wasn't so much unhappy with your performance, being a transport EMT has to be one of the worst gigs ever, you're sometimes given very sick patients to deal with, with little information or direction for how to intervene. Unfortunately, with the state of EMS as it is, you sometimes are put in a very bad position by a company that is run in less than a stellar fashion. I applaud you for knowing that there was an issue that needed to be dealt with, and I hope that some of these things bounced off you can be helpful.

[Just Plain Ruff]

So needles, you've been given some pretty stellar advice from several here.

I would go over this thread and think about what you can do to make your services service better.

Just be advised and take this as it's meant, be cognizant that my suspicion is that your service probably does not want to make a change. I'll bet that they are very comfortable operating the way that they operate.

They are comfortable performing at the status quo and by your offering suggestions for improvement will ROCK THE BOAT and that my friend is the surest way to end your job at that agency.

So you have to ask yourself one question. Are you willing to stand up to your company and fight for what you believe is the right thing (not transporting granny with a small bowel obstruction without pain meds) or are you willing to not?

Do you have the fortitude to go to the mat and push for reform in your service. Obviously a service who does these types of transfers without analgesic means, is not a service that I want my grandmother or my family member transported by if they need pain control. And you recognize that.

So what you need to do is to decide if you are willing to fight for better patient care on this issue or whether you are not willing to do so? If you are not, well then that's ok. It's only a job right? They are only patients, right?

But think of the difference you could make!!!

But a transport service without the ability to give narcotics to a patient in pain is a service that is obviously a service that has issues.

the balls in your court. What you choose to do with the ball is your decision.

Like the guy said in the third Indiana Jones when he was guarding the cup of Christ, "choose wisely".