Pain Management

[1EMT-P]

So let’s say you have a priority one trauma patient with open fractures to the radius & ulna plus tibia & fibula plus free fluid in the abdomen. The patient’s  vital signs are BP 100/60, HR 120 ST, RR 24, Spo2 95% on 2 LPM. The patients pain is 10 on a scale of 1-10. The ED that is transferring the patient has hung a unit of blood and gave orders for 0.1 mg/kg of Ketamine for pain. Plus 4 mg of Zofran IV x1 dose. This made the patient comfortable, but 1 hour into a 3 hour transport the pain returned. The medical command physician is contacted, but refused to treat the patients pain. What do you do?

Edited December 28, 2018 by 1EMT-P
Addition

[paramedicmike]

What are your treatment guidelines with regards to pain?

[Off Label]

Without the order, I guess you don't treat the pain. I wouldn't give an order for pain with what you've given here...what was the report to the doc? 

[1EMT-P]

Well here is the problem. The ED wrote orders for a one time dose of Ketamine & Zofran with orders to contact Medical Command for additional orders. The problem is the transport was 3 hours long. The Medical Command Dr was young & not a fan of Ketamine. There are no standing orders for pain management for inter facility transports.

[paramatt_]

Sounds like pretty poor planning / insight from the ED to not have a plan for additional analgeisa but is also something you should have considered and addressed prior to the transfer. 

Anyways, if I was in your situation I would have considered calling back the doc, putting them on speaker phone so they can explain to the pt their rationale for withholding additional analgesia and allowing the pt to remain in significant pain

Edited January 1, 2019 by paramatt_
spelling grammar

[paramedicmike]

No standing orders for pain control on interfacility transport?  I'm going to channel Dust a bit here: Your agency sucks.

What kind of advocacy did you attempt for your patient?  How many times did you call to ask?  If you weren't pestering them for orders every five minutes why weren't you?  What was the reasoning of the doc in question to deny  your request and to provide such short term pain management before the onset of transport?  What does it matter if the doc in question is not a fan of ketamine?

So many questions.

[1EMT-P]

I contacted the ED Physician, he said to contact the receiving ED Physician which I did three times. Neither Physician wanted to address this patient’s pain. Their reason was they couldn’t assess her if she was medicated. I explained to the Physicians that the patient was in severe pain and that she needed medicated, when I arrived I spoke with the Chief of Trauma and Anesthsia both of which agreed with me that the patient needed medicated and that the ED Docs were both wrong. The patient was given 100 mcg of Fentanyl IV, 4 mg of Zofran IV and an additional dose of Ketamine

[2wheelinemt]

This war on drugs have not stopped the use nor even slowed down the amount of illegal drugs coming into the use nor state to state. Only law abiding citizens are suffering!!!

[Just Plain Ruff]

 I second Dusts comment - from the grave

But couldn't you call the receiving facility and ask them for orders?  Tell them that the wussy doc sending the patient won't give orders and the patient needs them

 

I'll tell a little story

had a patient, history of brittle bone disease, going on a 2 hour transfer for a pain management consult.  2 lane roads all the way, terribly kept up roads.  

Was given a 10mg toradol PO pill and 15mg demerol prior to leaving the sending facility(it was the facility I worked at as a hospital based EMS medic). 1 hour prior to leaving she was given this huge dose of meds

20 minutes into the transfer, the roads get the best of her and she starts to cry out in pain.  

we are now out in the boonies, no cell service, we are also in the ambulance with the broken antenna so no radio service.  

So I go ahead and work via our standing orders for pain, start an IV, give her 25mcg's of fentanyl and some zofran.  that does the trick for about an hour.  I then dose her again.  All the while trying to make contact with the receiving and the sending hospital with NO luck. 

When we get there, the pain management doc goes nuts, he says I specifically said no pain meds on the transfer so I could evaluate her pain when she got here.  I told him the road condition and how much she was in pain.  He in front of the patient said He didn't care and refused to see her.  I told him that he would have to discuss that with her physician and that I would be making a complaint to the Missouri Medical Licensing board for his neglecting to treat the patients pain as well as making a complaint to the STATE.  (I did this by the way).  

He did agree to treat her now that the pain meds were on board for 2 hours and he said he guesses that he could go ahead and see her since she was here.  The patients family was really pissed off at the doctor, and myself and my partner were thanked by the family for making the patient as pain free as possible during the drive.  

 

We transferred her back to our hospital with new pain orders from the pain doctor after he saw what this patient had going on, I wrote all this up in my patient care report. Let my EMS medical director know what happened.  Our director of nursing reported me to the State bureau of EMS for prescribing medications without a license (I gave med's based on standing orders - he(nursing director)  didn't like that we had standing orders for anything).  the state came in, investigated, found me without fault since my medical director backed me and my ED nurse manager and EMS supervisor backed me as well due to radio failure and cellular failure.   

I told the director that I could have easily have reported this to the State as well due to the poor medication orders given for this patient as we all know that JCAHO and Nursing care everywhere feels that pain control is the new 5th vital sign.  

 

6 months down the road, there were mass layoff's (firings of 8 ER nurses and 6 paramedics - and I was the first to go on the day of the purge).  I know why, but hey, it sometimes sucks to be a patient advocate against such shitty nursing/physician care.  Tje state did find out about the failure to treat pain but it was a fall out of the complaint I made against the receiving pain physician and hospital she was transferred to, not the place I worked at but I don't believe my hospital was cited for this situation.  I do k now that I had to sit with an investigator and my supervisor for about 2 hours going over my run report and the entire transfer.  but the investigator was a nice lady and it wasn't too bad.  

 

 

[paramedicmike]

Analgesia does not inhibit or prohibit adequate or accurate evaluation of a patient or a patient's pain.  It's discouraging to see from this discussion that there are providers out there, specifically the two docs 1EMT-P encountered, who are unaware of this by both literature and direct practice.