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

[Kiwiology]

I don't think we have an adequate answer to the question of "Does intubation improve outcomes in medical cardiac arrests?" I think we have evidence leaning towards, "Prehospital intubations have a high rate of being placed in the esophagus which leads to poor outcomes."

Doing something when there is no evidence it has benefit is akin to voodoo and quackery; intervention without evidence should be dismissed without evidence.

(seeing pubmed on EMS sites makes me happy!)

LOL that is kind of funny

Is that ethical/legal? Can you intubate someone whose chief issue is agitation r/t mental illness? Very curious as to this line of thinking... to my thinking, RSI is a dangerous procedure with lots of potential sequelae involved with weaning them off the vent later, etc... can you justify it as a provider safety issue, based on those risks?

I am sure each day many thousands of people are electively anaesthetised and ventilated and then taken off a few hours later so that really wouldn't be an issue for me.

I do not agree with anaesthetising, paralysing and intubating somebody just because they're a bit agitated from a mental illness. Give them some ketamine and he'll be having a great snooze with none of that cardiorespiratory worry.

[ERDoc]

Doing something when there is no evidence it has benefit is akin to voodoo and quackery; intervention without evidence should be dismissed without evidence.

A great deal of what we do in medicine we do without evidence. Sometimes you have to do things because they make sense, in light of lack of evidence especially when it has become the accepted standard (and will remain so until a quality study shows otherwise). Is there any quality studies showing that fractures must be immobilized with rigid splints or is an ace wrap enough. Do you treat simple wounds with sterile precautions? There is plenty of evidence that shows you don't need to.

[mikeymedic1984]

Yes, lets please get back to the original thread. And just to add a little truth to something that was said: An INT does not meet ALS 1 requirements, if you are billing all calls with an INT as ALS 1, you will get a visit from the Feds at some point. Also to those who suggested that a 19 year old newbie cannot convince a Nurse to push pain meds for the ride, that may have been true 20 years ago, but these days most facilities/nurses are really good at pain management; I have never been denied this when transporting from a hospital or hospice.

Now if the patient was in severe pain (maybe being transferred for the ER), I agree to send ALS, but since this patient was pain-free or at least pain-controlled at time of dispatch, I see no need for ALS. By the OPs on admission, the patient was fine for the first 2 hours.

[Just Plain Ruff]

Yes, but once the patient began experiencing intractible pain after and hour and a half, she went above and beyond his scope of practice and an ALS crew should have been called into continue transport. If the patient required pain medications in the hospital and she was being transported to another hospital it was foolish for the transferring hospital to assume that the patient would not need pain medications at least sometime into that trip.

2 hours into a 5 hour trip the patient required pain meds.

Listen the OP has been beaten up over this with the dead horse and it's foal. He gets that and want's to make something like this not happen again.

He knows now that he could have called for ALS intercept for pain management and I am sure that in the future that is probably what he will do but then he faces the quandry of a job termination by doing so and in this day and age, doing what is best for the patient is likely to get you fired and then where will you be?? ON the streets, no job and probably no prospects of a job because the market SUCKS right now to get a job.

So maybe instead of calling ALS for intercept, diverting to the nearest hospital for pain management would be the most appropriate choice? That has not been floated as an alternative.

He could get the patient the pain relief she truly needed and his company could continue on with the transport and bill the patient for the transport.

[Kiwiology]

So maybe instead of calling ALS for intercept, diverting to the nearest hospital for pain management would be the most appropriate choice? That has not been floated as an alternative.

Perhaps, but what is he supposed to do? Wheel them through the front door into chairs and say to the nurse "this lady needs some pain meds?"

I'm not saying do not do it but it's a bit dodge; not sure how obliging the Physicians would be

It may have been put above and I haven't seen it but is this thing not supposed to be something your "medical control" is for?

Edited April 9, 2012 by Kiwiology

[Arctickat]

Class IIb evidence is evidence in which "usefulness/efficacy is less well established by evidence or opinion" and for endotracheal intubation is based upon level of evidence C which is "consensus opinion of experts, case studies, or standard of care"

Chuckle, yeah, but I use an Automatic Transport Ventilator when we do CPR which is class IIb, and to use one the patient must be intubated.

[mikeymedic1984]

Of the choices provided, stopping at an inbetween facility would have been best for the patient, but the inbetween facility probably would have had a hissy fit. To sit on the side of the road for 2 hours waiting for ALS does not seem to be the right thing (patient is still in pain). But again, to answer all of these weird freak occurence calls, you should always have on-line Medical Control to hash out these problems. I wonder if a manager was involved, I may have missed that part of the conversation.

[Kiwiology]

It's tragic that in the 21st century a first world nation still allows people who have no analgesia options whatsoever to treat people

I mean it's not like it's been known for thousands of years that treatment of pain is an important part of medicine

[Just Plain Ruff]

No Kiwi, what I'm saying is this, the patient is in intractible pain as per the OP. He should do this

He calls the receiving facility and talks to either the accepting physician or the ER

They tell him to divert to the nearest ED and they make a call to that ED or leave it to him to make the radio contact.

Lady gets pain medications. ER is pissy and Runs gets stabbed in back with phantom knives and daggers

Patient gets pain releif she needs and all is well.

World is back in proverbial orbit with not a single hair out of place.

[ERDoc]

As the ER physician that would receive this pt, I would have no problems caring for her, but she is going to get a chart generated. Unfortunately this is going to generate another ER charge that insurance will not cover. The question is, is she having more pain because her opiates have worn off or because something has happened?

As for medical control, just know that the doctor answering the phone will have no idea. We are great for medical issues/questions but for in-field logistics, you are probably better contacting someone who works on the road and understands how these things work.