Nubain

[flight-lp]

"When I got to the hospital, one of the residents ordered 4mg of Morphine, then told me I was ignorant for not giving anything for pain. Well one of the staff doctors walked in, saw the order, and then jumped all over his butt for giving morphine to someone who had 12 + beers and her blood alki level was unkown".

Hermann??

(Just a guess, sounds like somethin' they'd do!!!)

DAMN RESIDENTS!!!!!!

[Nate]

No it was the other one...good ole Ben Taub General Hospital. :wink: Since Baylor pulled out it is all UT residents, so the problems with Hermann have spread over there.

BTW, what the hell is up with Hermann's nurses being really cold and crabby? I remember when they use to actually enjoy their job, now most of them seem like they would rather be somewhere else. Granted every time I go in there I see new faces all of the time.

[mizzoumedic74]

Nalbupine was taken off our ground service about 2 years ago; our flight service still carries it yet, rarely uses it. We added Fentanyl to our trucks about a year ago and have had great results. However, the use of analgesics in trauma pt's w/ETOH on board is STRICTLY forbidden; also in the use of trauma pt's with suspected head injuries. A big reason behind this is because you cannot ascertain accurately if and where the pt is having pain with enough ETOH on board. You can progressively mask any further symptoms by the use analgesics as well as further blunting hypothalamus response.

You made the right decision. Great job.

[Doczilla]

I'm not a big fan of Nubain prehospital. It is a partial opioid agonist, meaning it also has some antagonist properties and will block some opiate receptors. While this means that there is a "ceiling" or limit to pain control provided by Nubain, it also means that it will antagonize morphine that will be given in the ER, further limiting pain control provided. Morphine is still the standard of care as far as pain control is concerned.

Tell the doc who gave you a hard time to get bent and read your protocols. He may disagree but he can't give you any crap about it on this particular topic.

You'll run into docs who feel differently on the issue of prehospital pain control, particularly in trauma. There is some theoretical concern that it will mask injury, and some concern that the effect combined with the alcohol will worsen airway status. There are docs who have the "cowboy" approach to trauma, where pain medication is withheld from intoxicated or injured victims and they are allowed to suffer in agony because they are afraid they might miss something on exam. We give it routinely on the trauma services here. Pain itself is a distractor that will mask less serious or subtle injuries, and I have seen people who, after some morphine helps bring their white-hot agony of their tib-fib fracture under control, become aware of injuries elsewhere. There has been the same thought given to abdominal pain, where some feel that narcotics will mask signs of a surgical abdomen. The studies have shown that it just ain't so, and we are fortunately moving away from the time when no narcotics would be given to an abdominal pain patient until surgery has evaluated them. I don't think there are any good studies out there on the injury-masking abilities of morphine when given appropriately in the trauma setting, intoxicated or not. As far as masking a head injury is concerned, they are getting a CT scan anyway (especially if they're drunk), so who cares? Serial neurological exams will be performed long after the alcohol has worn off, and I have not found them to be adversely affected by the morphine which is given routinely on the hospital floors to these trauma patients.

Bottom line is, I don't believe in letting patients suffer needlessly in the back of the truck. I seriously doubt that the BP or airway or clinical exam is going to be THAT compromised by 2-4mg of IV morphine given in a closely monitored environment, and if it does, then I can deal with it.

'zilla