giving Narcotics like candy

[JoelEMT]

I had a "discussion" with a Doc recently on this very topic... I had a pt with all the typical S/S of AMI and had our ALS unit come out to intercept. The 12-lead showed acute injury in the anterior leads. NTG does nothing to relieve the pain. Neither did Entonox (nitrous oxide). so the medic gave 2.5 mg of morphine. That seemed to help it dropped the pain from an 8-9 down to a 4/10. All of the desired "feedback-loop stuff" from the morphine kicked in and it very quickly improved our pt's presentation and VS. But O/A at the ER the doc gives us flack for giving the morphine. In fact, he went so far as to call all of us dumb (2 EMT's, 1 EMR and 1 medic as well as his 2 RN's that happened to be there.) (benefit of the doubt; perhaps he was having a bad day to begin with.) After letting him calm down for a few minutes, I asked him WHY he did not want us giving pain control of things like MI's.

His response was somewhat enlightening. He said: "they have pain, you treat that pain, then you bring the pt to me stating that they are complaining of chest pain, when I do my assessment they are no longer complaining of pain. Essentially, you have removed thier C/C. How can I, as a Doctor, perform an adequate assessment when the pt is now "feeling fine/much better"?"

I can see his point and yet, it is still in our protocols, nevermind in the pt's best interest, to control pain. Are we really looking out for our pt's "best interests (read - their continued health)" when we don't do all we can to help decrease the myocardial demands through Appropriate use of pain control agents.

Just my thoughts ( granted, I'm BLS, but I think my understanding of the concepts RE pain control at least, in this particular scenario, are correct. )

Correct me/ Educate me if I'm off the mark. Thanks

[Ridryder 911]

Well, unfortunately he is the one that is "dumb"... pain represents muscle dying, short and simple. So what if can't state the patient current c/c ... big deal! Does he not believe people when they in with a history of a fever or does he not want them taking a Tylenol before they come.... you mean he is not going to tx abdominal pain with N & V , prior to a surgeon looking ?..God forbid the surgeon not seeing the pain or N & V ... NO ! You tx the patient.

Hopefully, he had a bad night, and a not true asinine idiot.. if he wants he i.m. me & I will tell him myself ! Maybe he needs a good refresher of BASIC MEDICINE ...Due the patient no further harm .... HIM!

Be safe,

Ridryder 911

[kevkei]

Not really Kev, but enlighten me. I was hoping to learn something today........

Angingal equivalent: "no specific specific chest pain or discomfort, but the patient presents with sudden or decompensated ventricular failure (dyspnea) or ventricular arrhythmias (palpitations, presyncope or syncope)."

ACLS- Principles and Practice. AHA 2003. pp 397

"The concept of chest pain (anginal) "equivalents"

Many patients with ACS present with signs and symptoms that have been termed ischemic equivalents or anginal equivalents. It is important to note that these patients are not having atypical chest pain as described above. These are patients who seldom offer complaints of "pain" in the chest, below the sternum, or elsewhere, and the healthcare provider may not be able to elicit a report of such pain. Instead patients may present with a symptom or sign that reflects the effects of the ischemia on left ventricular function or electrical stability.

Patients with anginal equivalents are experiencing an ACS. They require the same assessment, treatment, and decision making as any other patient with STEMI or UA/NSTEMI. Note that this phenomenon os ischemic equivalents occurs much more frequently in patients having UA/NSTEMI than in patients having STEMI. Diabetic patients and the elderly are most likely to present with these symptoms. With advancing age, the elderly are more likely to present with diaphoresis.

Some of the more common chest pain equivalent symptoms experienced by these ACS patients are shortness of breath on exertion, weakness, fatigue, palpitation, and lightheadedness or near syncope with exercise.

The most common signs of anginal equivalents are acute pulmonary edema or pulmonary congestion, cardiomegaly, and a third heart sound. Ventricular arrhythmias can cause symptoms in these patients. Ventricular extrasystoles, nonsustained VT and symptomatic VT or VF have been documented. Ventricular ectopy that increases with activity (most will supress at increased sinus rates) is suspicious for ischemia. Atrial fibrillation is uncommonly an ischemic presentation."

ACLS for Experienced Providers. AHA 2003 pp 50.

[kevkei]

His response was somewhat enlightening. He said: "they have pain, you treat that pain, then you bring the pt to me stating that they are complaining of chest pain, when I do my assessment they are no longer complaining of pain. Essentially, you have removed thier C/C. How can I, as a Doctor, perform an adequate assessment when the pt is now "feeling fine/much better"?"

I agree with Ridryder, he is in fact, the one that is dumb. He doesn't need to assess the patient, all he needs to do is draw some blood and do a cardiac workup and look at your initial 12 lead and compare it to their serial 12 leads or any previous ones he has had done.

To allow your patient to stay in pain is barbaric and unprofessional. I would suggest that if you took the patient with pain 10/10 to be pain free with dynamic ST changes, you did an excellent job. I would suggest you talk to your medical director or another physician and even a cardiologist and get their opinion. I would be surprised to hear that anyone would agree with the doc that told you this.

By the way, where is he located to make sure I never see him?

[Dustdevil]

I suppose that same doctor gets upset if his patients are shot before they arrive at the ED. After all, if he doesn't see the injury occur, how can he adequately assess that hole in the patient's chest? :roll:

Ask him how the presence or absence of chest pain upon arrival changes his plan of action. Be prepared for a long, awkward silence. Or a bunch of irrelevant babble.

How old is that idiot? Are you sure he's not an intern?

[MedicShannon]

Ok I brought this up to my medical director and one of the trauma docs. And that doc that complained about giving pain meds with AMI is full of bull honky doo. From what I was told they do not want us giving any type of pain meds with ABD pain, or chest pain not cardiac related. They need to be able to assess the pain - location, severity, radiation, etc - and they can't do that if we give pain meds prehospital. So yeah that doc is full of bull.

[kevkei]

So now why do they want us to with hold meds in ABD pain too? This seems just as bad an idea. Clinically it has been proven you can give analgesia and still assess their abdomen, so why should we have to allow a patient to suffer?

[Dustdevil]

So now why do they want us to with hold meds in ABD pain too? This seems just as bad an idea. Clinically it has been proven you can give analgesia and still assess their abdomen, so why should we have to allow a patient to suffer?

I'd like to see if there has been any studies done on this, as opposed to us simply running off of old myths, like the so-called "Golden Hour." It appears the aim is to allow the physician as quality of an examination experience as possible in order to eliminate the need to do laparotomies on people to r/o surgical abdomens when they might have been able to rule it out through exam if the patient had not been gorked in the field. That is an admirable goal. But again, I would have to see studies showing that field administered analgesia actually impacts the surgical decision process in reality before I would be 100% for or against field analgesia in acute abdominal pain.

[kevkei]

I'd like to see if there has been any studies done on this, as opposed to us simply running off of old myths, like the so-called "Golden Hour." It appears the aim is to allow the physician as quality of an examination experience as possible in order to eliminate the need to do laparotomies on people to r/o surgical abdomens when they might have been able to rule it out through exam if the patient had not been gorked in the field. That is an admirable goal. But again, I would have to see studies showing that field administered analgesia actually impacts the surgical decision process in reality before I would be 100% for or against field analgesia in acute abdominal pain.

I agree, especially "to see studies showing that field administered analgesia actually impacts the surgical decision process in reality before I would be 100% for or against field analgesia in acute abdominal pain."

But in the interim, shouldn't there be a middle ground to try to make the patient comfortable? I don't think it is unrealistic to help take the edge off all the while them being able to aggrevate the pain at will. Not to mention, looking at maybe a shorter acting analgesic like Fentanyl as opposed to morphine?

Here is an iteresting read, albeit it isn't published material but provides good argument.

[web:a49a176380]http://www.ahcpr.gov/clinic/ptsafety/chap37a.htm[/web:a49a176380]

[Dustdevil]

But in the interim, shouldn't there be a middle ground to try to make the patient comfortable? I don't think it is unrealistic to help take the edge off all the while them being able to aggrevate the pain at will. Not to mention, looking at maybe a shorter acting analgesic like Fentanyl as opposed to morphine?

I'm completely with ya, Kev. I have always suspected that the case against analgesia for the acute abdomen has been overstated and unsupported by the evidence. But, as always, we have to live with the sacred cow until somebody gets the guts to slay it. That's a good article, and I hope that the author and others are actively pursuing definitive evidence to start some positive change in medical practice. The worst feeling as a paramedic is being unable to alleviate somebody's pain. It's worse than watching them die.