Do you ever feel annoyed?

[Kiwiology]

Continuing the practice may put your service at the risk of liability.

Continuing the practice may put your service at risk of looking archaic and inhumane too

[Asysin2leads]

Continuing the practice may put your service at risk of looking archaic and inhumane too

Well, there's that too, but unfortunately in today's world "Because its really, really wrong" stopped being sufficient reason to stop a practice a long time ago.

[croaker260]

Croaker, I've said plenty on my feelings on reducing injury without analgesia. A patellar dislocation is incredibly painful. Reducing it is very painful as well. Continuing the practice may put your service at the risk of liability. I know you're not the one making the decisions, but that practice needs to change.

Interesting thoughts , and on paper your statement seems legit. I respectfully submit that the reality (and my experience having done a fair amount of these) is different.

As you may or may not recall I am a huge fan of pain control for most orthopedic injuries. But I ask you to consider this:

Patellar dislocations themselves are EXTREMELY painful. The reduction, by contrast, is only more painful for about 20 seconds of the actual reduction itself, FOLLOWED by RAPIDLY DECREASING PAIN and relief. This results in a very unique situation in EMS pain control.

A patient without significant pain, but whom we have giver some relatively potent CNS depressants, and now faces related issues.

I have found that in the patients that I have medicated prior to reduction, post reduction (after the pain is resolved) respiratory depression is a concern since they no-longer have the painful stimuli, but still have the narcotics in their system. Not impossible to manage, but clearly avoidable in many (not all) cases.

The only way to avoid this paradox is by using conscious sedation techniques with extreemely short acting medications (i.e. propofol or etomidate) , with IMHO do not meet the risk - benefit analysis for field reduction, not to mention availability (well , we do carry etomidate).

So, in this situation, based on a case by case evaluation taking into consideration multiple factors (length of time of dislocation prior to EMS contact being a huge one), starting a line and pushing meds is seldom needed.

Besides I can typically have the basic assessment done, and the patellar reduced and the patient well on the way to non-pharmacological relief (ICE, support, etc) , well before my partner has the line set up and the IV started, much less having the medications drawn up.

Yes there are times in which I have medicated the crap out of a patient for reduction, but with analgesia comes risks. Easily mitigated, easily controlled, and easily screened risks, but risks none the less. We have a duty as paramedics to chose the best treatment for the patient, and anticipate all potential outcomes, and not treat just based on a protocol. In our cases, our protocols give us liberal options, and the ability to decide the best route.

So, in reply, I understand your statement, and agree with the sentiment, but disagree with it ALWAYS being needed in this situation. From a risk/benefit analysis, Rapid (uncomplicated) non-medicated reduction trumps delayed medicated reduction with all the potential risks that entails, especially considering the immediate relief that follows.

Respectfully submitted

Steve

Edited April 16, 2012 by croaker260

[Asysin2leads]

As person who once suffered a patellar dislocation, I can tell you that the pain is something you don't want to suffer 20 seconds with. As paramedics, we have several forms of airway control, as well as narcotic antagonists. Granted, analgesic effects can be different in pediatrics, the elderly, people with depressed liver functions, or people on either end of the BMI scale, but in general practice, if you have communication with an experience physician, the analgesics, sedatives, and amnesics that we carry can almost always be administered safely.

Personally, I was given midazolam prior to reduction, and I can report that it is very effective, and its short half life is very beneficial if you are concerned with respiratory depression. You know, I had this almost same discussion with someone about the same concerns with succinylcholine. I had never given succinylcholine, but I was quite familar with its pharmacodynamics, and it always made me scratch my head about the gloom and doom warnings about being unable to intubate after giving it. In my mind, if you have a drug that wears off in 3-5 minutes, you should be able to control the airway and ventilate using BLS adjuncts for 3-5 minutes until such time. The quip the instructor made was "Yes, but that could mean that for 3-5 minutes the patient's life could possibly depend on the BVM skills of a medical student and some rookie nurses." Point taken.

Anyway, with the current push in standard of care to aggressively manage pain control, I think its possible that at some point, it could be a liability issue if your service continues to reduce painful, deformed extremities without analgesic.

Edited April 16, 2012 by Asysin2leads

[croaker260]

A2L:

RE: Succs and RSI/MAI : Having about 14 years experience using a variety of induction agents in RSI.MAI, I can tell you the reality can be far worse that what words on paper can portray. Its like anything else in airway management... its easy to do...until it aint. And when it "aint"...its a nasty furball. This statement isnt specific to succs, but to the whole process. You may do RSI a hundred times without problem, or once. You never know.

I remain a huge proponent of RSI/MAI, dont get me wrong. But until you have seen it screwed up by well meaning and well educated providers who are doing everything right...and things still go wrong...its just something thats hard to convey over a forum.

RE: you comment on narcotic antagonists: OK, this is a pet peeve of mine... a HUGE pet peeve. SO bare with me. But if any of my paramedic students, my interns, or my FTEP newbies...... EVER implied that they werent worried about giving too much of an opioid because they had narcan, they wouldn't be pushing any meds at all until they could adequate relate and articulate all the potential "Oh SHIT" situations from such a calvalier approach to medications. And as strongly as I feel about that, I feel DOUBLY so regarding Romazicon (A benzo antagonist).

I know that you didnt mean to come a across as cavalier, but its a hot button of mine.

RE: Versed. Its not that I cant manage the respiratory sedation, its that it doesnt meet the risk vs. benifit analysis in my descision process in many of these cases..

As a side note- I would use Valium instead...better anti-spasm properties and all that and less respiratory depression, even though it lasts longer than versed, its simply better for this situation. Assuming you want to actually reduce the injury easily. If you just want to manhandle it back into place but not have the patient remember it, then I guess versed is better.

But thats not the point. The point is that you can safely , humanely , and promptly reduce a (recently injured in the prior 15 minutes) patellar dislocation without the risks of medication administration, as well as the complicating after effects. This allows a more cost effective, less resource intensive, and a more targeted treatment specific to the patient. This is a HUGE deal in back country.. because it can mean the difference in a patient limping out on a goat trail, and being carried out with a multi-tiered robe rescue evolution or a short time...both of wich are more risky. Its also a huge deal with any patient in routine EMS operations. Sure you can knock down every patient that has a sprained ankle to splint..and some you probably should. but not all of them.

Imagine explaining to the doc why your patient aspirated when they had an atypical response to the benzo, and then due to unanticipated issues you were unable to control the airway, when you gave the benzo for a relatively painful but otherwise minor and non-life threatening injury to begin with.

Its the whole risk vs. benefit thing. Sometimes it makes sense to medicate...most of the time in these situations it does not. In otherwords..always pretend Mr. Murphy (as in Murphy's Law) is peaking over your shoulder waiting for you to slip up. Cross paths with Murphy only when you absolutely need to. (and when you do, have some Paramedic Voodoo in your back pocket...)

Edited April 16, 2012 by croaker260

[Asysin2leads]

I wasn't trying to be cavalier about narcotic agonists. I brought it up because in a risk/benefit analysis, it is another layer of safety. Morphine does have one of the narrower therapeutic indexes, but in the hands of a skilled provider it is can be administered fairly safely. Having an antagonist on hand is an extra layer of safety on top of that. The chance of overdosing the patient on morphine may or may not be unacceptably high, but the chance of a narcotic overdose times the chance of the antagonist not working significantly reduces the probability of having a life-threatening event.

Of course I don't recommend using a simple opiate for extremely painful procedures. That's why I prefer a combination of an analgesic and a sedative/hypnotic or a sedative/amnesic. I also don't think its proper to imagine a worst case scenario, and then apply that logic to EMS operations as a whole. Sure, I can think of 100 scenarios that would necessitate a dislocation reduction without analgesia, you're example of being in the woods and unable to do anything but get the patient to the self-evacute would be one of them. Under fire in Iraq would be another. But doesn't mean that since its okay to do that in those situations, then its what should constitute general operating procedure.

To answer your question, if I gave a sedative or analgesic, and the patient started vomiting, and the patient then aspirated on that vomit and caused severe complications, and I wasn't able to intubate, and I wasn't able to ventilate using BLS adjuncts, then I would say that is multiple failures on multiple levels and that even the Space Shuttle blows up sometimes.

I am of the mindset that the prehospital practice should follow in-hospital practice as much as possible. I'm sure the ER attendings could think of a few scenarios that would preclude the use of analgesics during a reduction, but I'm sure they frown upon it as the general way of doing things. Putting someone in unnecessary pain because of possible risks that can usually be mitigated is not ethical nor humane. I should note that it is really only in the United States that lower levels of providers are denied any use of analgesics. Most first-world countries allow providers with lower than paramedic-equivalent training to administer some form of analgesic, even if its simply Nitrous Oxide. Its only in the US (in most places) that anyone under the care of anything less than a full paramedic gets a hand to squeeze on and not much more.

I've never had an RSI go wrong, the closest I've ever had was a couple of heroin overdoses when I was working BLS and had a short transport time to the hospital. We were able effectively bag someone in respiratory arrest until we got to our destination. It wasn't easy, it wasn't something I can recommend, but it is entirely possible.

I liken pain control to rappelling down a cliff. When you're at the bottom, looking up, it looks easy and not that high. Its only when you yourself clip in and start backing towards the edge that you get a full appreciation of what the experience is like. I think its very telling that providers who themselves have suffered painful orthopaedic injuries are more aggressive in pain control than those who have not. When you're in pain yourself, then it becomes clear what 10 minutes to the hospital feels like, or 20 seconds of reduction feels like, or how effective verbal techniques really are.

[Inthecity]

It is very interesting to try and read the different perspectives (although I admit I have a hard time with some of the medical talk and lingo!). It seems many people would not give morphine for a patella dislocation? After I dislocated mine the firefighters came first. They said as soon as the paramedics came I would get some morphine. It took the paramedics about 10 more minutes to get there and I would have cried if I could not have received morphine when they arrived! Im pretty sure that the started an iv line and the morphine while they were still in my house. I would have thought that happened in the ambulance but I was SO happy to get the morphine. He gave me 4 doses and said by law that was the most he could give. He said there would be a wait for the orthopedic doctor to come in so he wanted to dose me up for the wait. He was nice

[Kiwiology]

He gave me 4 doses and said by law that was the most he could give

What he meant is that is the most the standing order from his physician medical director delegating the ability to supply and administer prescription medication without a license to practice medicine permitted him to administer

Gosh I am glad we don't have such here

[croaker260]

I also don't think its proper to imagine a worst case scenario, and then apply that logic to EMS operations as a whole.

Well, you and I may have a different concept here, but I think it should be mandatory for any EMS provider to bve aware and consider the "worst case scenario" as a matter of routine. I am not saying this induce paralysis of action, but its part of critical thinking and decision making. When the space shuttle blows up, its a tragedy. When it blows up due to a reasonably foreseeable event or simple failure to think things through, its criminal.

I am of the mindset that the prehospital practice should follow in-hospital practice as much as possible. I'm sure the ER attendings could think of a few scenarios that would preclude the use of analgesics during a reduction, but I'm sure they frown upon it as the general way of doing things. Putting someone in unnecessary pain because of possible risks that can usually be mitigated is not ethical nor humane. I should note that it is really only in the United States that lower levels of providers are denied any use of analgesics. Most first-world countries allow providers with lower than paramedic-equivalent training to administer some form of analgesic, even if its simply Nitrous Oxide. Its only in the US (in most places) that anyone under the care of anything less than a full paramedic gets a hand to squeeze on and not much more.

Ironically , it was our own docs who facilitated this protocol, and encourage its use with and with out analgesia. A patient who has not been medicated can be sent in POV, be triaged, admitted, and in and out of the fast track side with an xray and a referal, having received an evaluation, in under an hour. They technically dont have to go to the ER, and can follow up with the clinic.

By contrast, A patient who has received narcotics get an IV, a full ALS evaluation, and an ambulance ride that can only take them to an ER (the most expensive place on earth to get medical care) where they require a monitored bed, and typically 4 hours observation time minimum, and the resources that can /should be used for more ill patients. That's assuming nothing goes wrong.

Of course I don't recommend using a simple opiate for extremely painful procedures. That's why I prefer a combination of an analgesic and a sedative/hypnotic or a sedative/amnesic.

On this you and I agree.

Putting someone in unnecessary pain because of possible risks that can usually be mitigated is not ethical nor humane. I should note that it is really only in the United States that lower levels of providers are denied any use of analgesics. Most first-world countries allow providers with lower than paramedic-equivalent training to administer some form of analgesic, even if its simply Nitrous Oxide. Its only in the US (in most places) that anyone under the care of anything less than a full paramedic gets a hand to squeeze on and not much more.

This is where you and i are miscommunicating. I am not putting them in pain, they are already there. I am saying we have a less invasive, less complex, more cost effective, less resource intensive option than doping the patient, that is QUICKER. It is not an option for all patellar reductions, but many of them.

Again, I am all for pain management. Liberal pain management. Every day. And Twice on sunday. But I have seen both approaches work out , and think its mono-optic and dogmatic to not to consider them both.

You and I are in agreement on the lack of BLS pain management options. But I think that the BLS levels need more educatio to go along with it. But I think they need more education period.

I've never had an RSI go wrong, the closest I've ever had was a couple of heroin overdoses when I was working BLS and had a short transport time to the hospital.

Well I have. I have been fortunate enough not to be lead on them, and have learned from the mistakes. But the biggest lesson is the horrible feeling that you get when you know the patient is worse off because of something you did that you really didnt have to do. I will leave that discussion for another time.

I think its very telling that providers who themselves have suffered painful orthopaedic injuries are more aggressive in pain control than those who have not. When you're in pain yourself, then it becomes clear what 10 minutes to the hospital feels like, or 20 seconds of reduction feels like, or how effective verbal techniques really are.

Again, I am very for liberal pain relief. And I have medicated patella dislocations previously as well. At my service we literally use more morphine than albuterol and Zofran combined, or any other drug. And I have had several ortho injuries, and also kidney stones. (BTW, kidney stones are worse...) THese experiences have taught me the importance of targeted interventions patient specific interventions, not just shotgun interventions. But 22 years has also given me a perspective of multiple approaches, and sometimes the best approach, isnt the obvious approach.

Anyway, perhaps this is one topic you and I can agree to disagree and still respect each other in the morning.

Respectfully submitted

Steve

[Asysin2leads]

There's no disrespect intended. I'm not saying that manipulation of a fracture or dislocation without analgesic is always wrong, and indeed, if your service has found a way to reduce or manage injuries and be able to do it efficiently and without negative feedback, then good on you. However, your service should be familiar with the standards for timely pain relief that JCAHO and/or Medicare expects. Speaking of worse case scenario, you have to bear in my mind you might get that one asshole patient who you did absolutely superb work on, and got them up and gone for cheaper and better, but who has a cousin who knows a lawyer who can get him a few bucks, and is able to bring in the standards of pain relief to court and show what you "should have" done.

I think pain relief is the one single issue that modern healthcare screws up the most for the largest population. We under treat acute pain, both because of the limits of EMS and attitudes that haven't quite caught up with research, and we over treat chronic pain, turning somebody with a simple lower back muscle strain into a sedentary invalid knocked out on hydrocodone or carisoprodol, who needed a few days rest and then needed to stretch and exercise.

I trust your medical judgement, I tend to be very aggressive on pain management much because of my own injuries. I'll be the guy who volunteers to be dropped off in the woods in the middle of the night even if its just for some pain relief on a person with a dislocated patella, because I know how much it hurts, and I don't want other people to have to go through that if it can be avoided.