giving Narcotics like candy

[MedicShannon]

The worst feeling as a paramedic is being unable to alleviate somebody's pain. It's worse than watching them die.

It is the worst. We have kidney stone protocol now... very prevalent here for some reason. Certain criteria need to be met before we can admin pain meds. Right now all we carry is morphine. Would love to see other meds available, but we are lucky to have what we have.

[Ace844]

Hi All,

To get us back on topic abit, I thought I'd post a copy of these recent studies.....Any comments...thoughts...???

COMPARISON OF PERCEIVED PAIN WITH DIFFERENT IMMOBILIZATION TECHNIQUES

The sensitivity of cardiac markers stratified by symptom duration

Prevalence of acute myocardial infarction and other serious diagnoses in patients presenting to an urban emergency department with chest pain

Potential diversion rates associated with prehospital acute myocardial infarction triage strategies

Non-Myocardial Infarction Chest Pain

Psychiatric Issues in a General Cardiology Practice

PREHOSPITAL PAIN MANAGEMENT

A COMPARISON OF PROVIDERS' PERCEPTIONS AND PRACTICES

Halim Hennes A1, Michael K. Kim A1, Ronald G. Pirrallo A2

A1 Department of Pediatrics, Pediatric, Emergency Medicine Section, Milwaukee, Wisconsin

A2 Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin

Abstract:

Objective. To assess the knowledge of emergency medical technicians–paramedics (EMT-Ps) and compare their practice perceptions with actual pain management interventions in adults and pediatric patients (adolescents and children) with chest pain (CP), extremity injuries, or burns. Methods. This study included a cross-sectional survey of EMT-Ps and review of the emergency medical services (EMS) system patient care database. EMT-Ps were surveyed for: 1) knowledge of pain treatment protocol; 2) estimated number of CP, extremity injury, or burn encounters and the frequency of morphine administration; and 3) barriers to providing morphine. Data on patients transported with any above conditions and those who received morphine were abstracted from the EMS patient care database. Data were analyzed using descriptive statistics, and 95% confidence intervals (CIs) were calculated. Results. Of 202 EMT-Ps, 155 (77%) completed the survey. Eighty-two percent reported knowledge of pain treatment protocol for both adults and pediatric patients. For adults, EMT-Ps estimated they administered morphine to 37% with CP (95% CI 35, 40), 24% with extremity injuries (95% CI 17, 30), and 89% with burns (95% CI 52, 99). In children and adolescents, inability to assess pain (93%) was the most common reason for withholding morphine. According to the EMS database, 5% of adults with CP (95% CI 4, 5), 12% extremity injuries (95% CI 8, 15), and 14% burns (95% CI 8, 20) received morphine. In children and adolescents, 3% with extremity injuries (95% CI 1, 5) and 9% with burns (95% CI 0, 26) received morphine. Pain score was documented in 67.0% of adult patients, compared with only 4.0% in pediatric patients (? = 63.0%, 95% CI: 60, 65). Conclusions. Significant disparity exists between EMT-Ps' perceptions of acute pain assessment and the frequency of providing analgesia and their actual practice. Children and adolescents had less documentation of pain assessment and received less analgesic interventions compared with adults. Inability to assess pain may be an important barrier to the provision of analgesia.

PREHOSPITAL PAIN MANAGEMENT IN CHILDREN SUFFERING TRAUMATIC INJURY

Robert Swor A1, Christine M. McEachin A1, Debra Seguin A1, Kristi H. Grall A1

A1 Department of Emergency Medicine, William Beaumont Hospital, A Wayne State University Affiliated Program, Royal Oak, Michigan

Abstract:

Prehospital pain management has become an important emergency medical services (EMS) patient care issue. Objectives. To describe the frequency of EMS and emergency department (ED) analgesic administration to injured children; to describe factors associated with the administration of analgesia by EMS; and to assess whether children with lower-extremity fractures receive analgesia as frequently as do adults with similar injuries. Methods. This was a retrospective study of children (age < 21 years) who were transported by EMS between January 2000 and June 2002 and had a final hospital diagnosis of extremity fractures or burns. Secondarily, children with lower-extremity fractures were compared with a cohort of EMS-transported adults with similar injuries and transported during the same study period. Receipt of and time of parenteral analgesia were recorded. Results. Seventy-three children met the inclusion criteria. The mean (range) age of this sample was 12.4 (0.9–21) years, with only four patients aged < 5 years. A majority of the patients were male (49/73, 67.1%) and sustained femur (20/73, 27.4%) or tibia/fibula (26/73, 35.6%) fractures. Few pediatric patients received prehospital analgesia (16/73, 21.9%), while a majority received analgesia in the ED (58/73, 79.4%). Prehospital analgesia was associated with earlier patient treatment than that administered in the ED (22.3 ± 5.9 min vs. 88.3 ± 38.2 min). Comparing children (n = 33) with adults (n = 76) with similar lower-extremity fractures, a small insignificant difference was found in the rate of prehospital analgesia between children and adults (7/33, 21.2%, vs. 20/56, 26.3%). Conclusion. Few pediatric patients receive prehospital analgesia, although most ultimately received ED analgesia. Few factors were identified that could be associated with EMS oligoanalgesia. No difference was found between children and adults in the rates of EMS analgesia.

THE FEASIBILITY OF PAIN ASSESSMENT IN THE PREHOSPITAL SETTING

Samuel A. McLean A1, Robert M. Domeier A1, Heather K. DeVore A1, Elizabeth M. Hill A1, Maio DO, MS A1, Shirley M. Frederiksen A1

A1 Department of Emergency Medicine, University of Michigan Medical Center/St. Joseph Mercy Hospital (SAM, RMD, HKD, EMH, RFM, SMF), Ann Arbor, Michigan.

Abstract:

Objective. To determine the feasibility of prehospital pain measurement among patients 13 years of age or older using a verbal and numeric rating scale and to assess the severity of pain in a prehospital patient population. Methods. Retrospective cross-sectional study of emergency medical services (EMS) run sheets after the adoption of a universal prehospital pain assessment protocol. Data were abstracted from a sequential (1:4) sample of run sheets from the first three months after adoption of the protocol. Verbal rating scale (VRS) and numeric rating scale (NRS) pain assessment information was obtained, along with demographic, location, and call information. Run sheets without pain assessment underwent structured review and classification according to predefined protocol. Descriptive statistics and 95% confidence intervals were calculated. Results. A total of 1,227 run sheets were reviewed, 582 (47%) of patients were male, and 452 (36%) were 65 years of age or older. A total of 907 (75%) were nontrauma transports and 27 (2%) were unconscious. Among conscious patients, pain was assessed using the protocol in 1,002 of 1,200 (84% [range, 81%-86%]). Among patients reporting pain, 104 of 518 (20% [range, 17%-24%] completed a VRS but not an NRS. The greatest risk factor for no pain assessment was altered mental status (39% of patients not assessed). Forty-eight percent (23 of 48) of patients with altered mental status reporting pain completed a VRS only. Thirty-one percent (range, 28%-34%) of all patients in the sample reported moderate or severe pain. Conclusion. Prehospital pain assessment using a VRS and NRS was feasible in this patient population. Further studies are needed to confirm this finding in other settings. Moderate or severe pain was present in approximately 31% of patients.

Hope this helps,

Ace844

Please refer your doc to the studies above, as well as "Rid" for further education....It seems to me like your law dept...may be getting very busy in the near future..!?!?!?!!?

out here,

Ace844

[Apheration]

I've been in rehab since feb. There was one dude (actually my house manager) who jokingly said yeah man you ever get taken to the hospital, tell them you're allergic to everything except demerol that shit fucks you up !!

[zippyRN]

It is the worst. We have kidney stone protocol now... very prevalent here for some reason. Certain criteria need to be met before we can admin pain meds. Right now all we carry is morphine. Would love to see other meds available, but we are lucky to have what we have.

'renal colic' is a classic drug seeking presentation.

in the UK it is now customary to gie PR or injectable NSAIDs o and /or buscopan as first line management rather than an opiate -

IIRC some ambulance services are carrying injectable NSAIDs as an 'intermediate' levle of pain relief

[Ace844]

Here's yet another study which shows pre-hospital analgesia to be safe and effective...

Hope this helps,

Ace844

Impact of Liberalization of Protocols for the Use of Morphine Sulfate in an Urban Emergency Medical Services System

James E. Pointer A1 and Kristine Harlan A2

A1 Alameda County EMS, San Leandro, California

A2 American Medical Response, Northwest/Plains Division, Roseville, California

Abstract:

Objective. To investigate the impact of liberalization of paramedic management protocols for the use of morphine sulfate (MS). Methods. A retrospective database analysis tallied and categorized MS use into seven conditions during two intervals—six months before (control) and six months after (study) the protocol change. Results. In the control interval, 760 of 34,020 (2.2%) patients received MS. In the study interval, 999 of 30,320 (3.3%) received the drug, a 50% relative increase in MS use. MS use dramatically increased in two assessment categories: other painful medical conditions (19.0% vs. 2.8% of transports, relative risk [RR] 6.8, 95% confidence interval [CI] 5.2–8.9) and nontraumatic abdominal pain (9.2% vs. 1.9% of transports, RR 4.8, 95% CI 3.3–6.9). Conclusion. Liberalization of pain management protocols resulted in an appreciable increase in the use of MS only in medical categories, predominantly abdominal pain, with no apparent safety or misuse issues.

[MedicShannon]

Renal Colic may be prevalent for drug seekers, but we have a lot of documented cases of renal colic - true stones. most of our seekers complain of back pain, uncontrolled abd pain (IBS, Crohns), Neuropathy, etc.

Now correct me if I am wrong; when someone is in severe 10/10 pain, they will exhibit one or more of the following -

elevated BP

elevated HR

elevated RR

some diaphoresis

agitation

anxiety

If one of these aren't present, esp in renal colic, I will start an IV but may not give pain meds. And just fyi, our transport times are 10 minutes or less (mostly less).

[Ace844]

Renal Colic may be prevalent for drug seekers, but we have a lot of documented cases of renal colic - true stones. most of our seekers complain of back pain, uncontrolled abd pain (IBS, Crohns), Neuropathy, etc.

Now correct me if I am wrong; when someone is in severe 10/10 pain, they will exhibit one or more of the following -

elevated BP

elevated HR

elevated RR

some diaphoresis

agitation

anxiety

If one of these aren't present, esp in renal colic, I will start an IV but may not give pain meds. And just fyi, our transport times are 10 minutes or less (mostly less).

Yes, but remember there are other factors involved which a thorough H@P will allow you to "dope" out if you will. For example,(just a quick and obvious one off the top of my head) if your patient is on a Beta blocker they will be unable to "show" sympathetic s/s's of pain/shock....that's why it is necessary to look at the whole presentation...

Also, the data speaks for itself, we don't adequately treat pain in the pre-hospital environment....

out here,

Ace844

[canuckEMT]

Kev, thank you for the reply and explanation of the term.

Joel, that Doc there had a bit of an EGO problem, and with the report given by the attending Medic, I think he should have been able to properly assess the Pt's pain.

I was recently involved in a teleconference in-service in the Calgary health region about STEMI's and criteria for direct transport to the cath lab. The head of the Cath lab was stating he is in favor of Fibronolytics being administered by EMS where transport to the cath lab was greater than 90 min. And also stating that EMS should keep the Pt as comfortable as possible during transport.

If all fails, treat according to your local protocols and advise recieving Doc of such a fact. Tell him he is more than welcome to call one of his colleagues a MORON for developing that said protocol......

[FireMedicChick164]

we don't carry narcs on my vollie rig...at work the medics carry narcs....never seen em used yet...

I totally agree with managing pain though. I have a recent example having to do with me.

Monday at work I crushed my finger between the stretcher frame and the release lever while we were loading a patient into our rig....broken finger...my partner and I watched it swell as I waited for the stars to fade from my vision and tried not to pass out. So after I got my bearings I splinted my finger, slapped an ice pack on it and got in the back of the rig with the patient (we were taking her to the ER for abnormal labs) and we proceeded hastily to the hospital where we delivered the patient to s bed and then I signed in to get my finger looked at. After I saw the triage nurse and reporting my pain was an 8 they gave me Tylenol and sat me in a chair by x-ray..no I have a very high tolerance for pain but this FREAKIN' HURT! The Tylenol didn't touch it....needless to say when I got home afterward I took some Benadryl and some Vicodan that I had and slept for 12 hours....that was 2 days ago...my finger is still blue in spots and swollen to the size of a hot dog and kinda gross looking and the Tylenol is finally controlling the pain. So much for effective pain management!!

[Dustdevil]

Dude, that ER sucks! I would never go back there.

I sprained my ankle on the job once. Got taken to the hospital in my own ambulance, and wheeled into the ER by my own partner on my own cot. I thought for sure it was fractured, but it was just a major sprain. That didn't stop them from giving me Demerol/Vistaril and a script for Vicodin. And I am sure your finger hurt at least as much as my ankle did. That's just wrong.