Do You Feel You Have the Ability To Adequately Control Pain?

[katbemeEMT-B]

Plus 5.

This is more of the "public safety" mentality nonsense that permeates and soils EMS. People think because they have a uniform and red lights that they are now somehow responsible for law enforcement and criminal investigations. Wanna be a super sleuth? Quit EMS and go to the police academy. But right now, it ain't your job. Seriously, what do you care if you get played by a seeker? You gonna lose sleep over it? You're going to lose a lot more than sleep if you peg the wrong patient as a seeker. Your MD is going to rightfully label you an idiot, and you're sacked.

I'm not the one labeling the seekers. If you read what I posted we call Med Control and they make the decision as to whether or not the pain meds can be administered. They have the records of these patients available to them. We give them patients name, birthdate, c/c, vitals, and any other information we have on them that we get from the patient or bystanders. Med Control makes the call. We treat them regardless to the best of our ability. If it's a major trauma such as a broken bone, severe lac., or to that effect we can give morphine after IV access has been obtained. If we are unable to obtain access we need to call Med Control for IM administration. I only used that one pt as an example of how obvious and stupid some seekers really are.

Another example why this is important is the 48 y/o/m patient we transported for an obvious knee injury. He was in tremendous pain and allergic to morphine. Med. Control was contacted and we were unable to give him anything else except to put ice on it. I don't know why so I can't tell you that. His wife did tell us at the hospital that he is on some pretty heavy medications so I would assume it has to do with that but I can't be sure. I didn't ask because frankly, it's none of my business.

I'm sure we have treated seekers. I know I'm not psychic and neither are the people I work with. We can't tell who they are all the time. It's just some times they are obvious. Even the obvious ones are still assessed and get treatment, just not drugs (which isn't our call to make) unless they have a major injury or are cleared by Med Control. By no means do we call and say, "Hey I think we got a seeker here, what should we do?" That would be ass-a-nine. We don't even give subtle hints that we suspect. But as I said, to my knowledge, it's not a big problem here. We are more of a rural area. It's a bigger problem in the metro area. Around here they would rather smoke weed. When I say weed sometimes it's really weeds.

[theotherphil]

Your pain control management should not be set up to deny access to people you think might be seekers. It should be set up to provide pts in pain with appropriate medication. Furthermore, people can have legitimate pain without the outward appearance of injury or deformity and/or a change in vitals. You system is flawed because your rationale for pain control relies solely upon your judgement of how bad you think the pts pain is. While the Paramedics impression should certainly weigh in on the use of pn meds, the pts impression should also have equal bearing; depending on severity (0-10). Using the 1-10 scale is a quantitative approach, while using your impression is a qualitative. Which method is more suitable for protocol? And remember that seekers can actually have real conditions that may require analgesia.

It seems as if your pain management protocol is in need of a rehaul.

I would rather medicate a 100 seekers with protocol doses of analgesia then let one old lady with abdominal pain suffer all the way to the hospital in my ambulance. And this is how your pain management should be approached.

This is exactly how I see things. It really doesn't bother me if I get caught out by a seeker - I know that everybody I treat gets adequate pain relief. A vial of Morphine costs pennies which I don't pay for.

[katbemeEMT-B]

This is exactly how I see things. It really doesn't bother me if I get caught out by a seeker - I know that everybody I treat gets adequate pain relief. A vial of Morphine costs pennies which I don't pay for.

I understand what you're saying and I'm not saying pain management is not our number one priority; as it is. What I am saying is that we have certain protocols we have to follow. Why they are there, I don't know but I do know that the surrounding hospitals also have them. I also know that seeking is not a huge problem in our area and maybe that's why. The woman in my example drove 120 miles one way twice in one week to obtain drugs from us. The only reason I know so much about this other than what she told us is she was arrested after the second time for possession and we were in court during her hearing to testify. She apparently had pot in her pocket that fell out in the hospital.

We also depend on Med Control to help us out when we run out of options. We have limited resources for pain control but I have never heard a patient we transported come back and say you didn't do enough to control my pain. We are hospital based and the hospital sends out surveys to it's patients. From what I have seen 99% of the surveys coming back have excellent marks for the care they received from us. The 1% usually pertains to their rough ride and one joker thought it took too long to respond for his broken toe. We were 15 miles away and got there in about 14 minutes. Two lanes road, heavy traffic, bunch of retards that don't know what the siren is for. Call came in as unknown fracture, 68 y/o/m. We assumed it was probably a hip. Once on scene discovered it was a 58 y/o/m with a broken toe too drunk to take himself to the doctor. :violent1:

So maybe it isn't perfect but at least we have some options on the ALS service. Some services around us have no options for pain control as they are BLS only (I happen to work on one of them in addition to the ALS service). Those are the patients I feel for. It comes down to this; educate me more (as I continue to educate myself) and give me the tools I need to make my patients as comfortable as possible.

Sometimes it's not actually the pain but fear that is affecting the patient. It is our job to be able to differentiate between the two because both can be dealt with. An example: We had a 12y/o/m with a grossly deformed broken forearm. After giving him the max ped. dose of morphine for his weight he insisted he was getting no relief. We contacted MC and he had us administer an additional .2mg. He still insisted he was getting no relief. I was busy keeping the arm stabilized as there was really no good way to do that and my partner got "Timmy's" (not his real name) attention and distracted him. By distracting him my partner was able to keep him calm and not think about the pain while the morphine did it's job.

[Dustdevil]

What I am saying is that we have certain protocols we have to follow. Why they are there, I don't know but I do know that the surrounding hospitals also have them.

You have protocols that you do not understand? :shock:

Have you made any attempt to understand them?

How long have you been working there?

Does your MD know you don't understand your protocols?

[ERDoc]

A vial of Morphine costs pennies which I don't pay for.

There is so much more to it than just the cost of the morphine. Drug seekers have an enormous impact on the costs to society (though I cannot speak for the system in the UK, only in the US). Who do you think pays for the ER visits for all of these people? Most of them will have medicaid (which the taxpayers pay for) or no insurance (the hospital will then pass the costs on to those who can/will pay their bills). Then there is the impact they have on the ER itself. They take up a bed that could be used by a person who really needs it. They take up the time and resources of the doctors, nurses, tech, etc that take care of them. When they call an ambulance they are taking up a ambulance that could be used by someone who truly needs it (and they likely will not pay for it). The US healthcare system is busting at the seams and is ready to collapse. These people are only making the situation worse. Their impact is much more severe than just the cost of the vial of morphine.

I am not saying not to treat people for pain (read some of my previous posts and you will see I advocate just the opposite), but when you have been in the field long enough you can spot BS coming through the door. I explain to these people that the ER is an inappropriate place to treat their chronic pain problems. I also tell them that it would be inappropriate for me to treat their chronic pain with the 4mg of Dilaudid (which I feel is one of the worst drugs ever created) that they ask for. So, while it may not seem like a big deal to give a drug seeker their hit once in a while, keep in mind that there is a much larger picture than what you have to deal with in the back of the of the ambulance.

I'll step off of my soapbox now and return you to your previously scheduled thread.

[katbemeEMT-B]

You have protocols that you do not understand? :shock:

Have you made any attempt to understand them?

How long have you been working there?

Does your MD know you don't understand your protocols?

Sorry for misstating that. It isn't that I don't understand the, I do. Part of our training even as an EMT-B is to memorize and understand all protocols. The test we are given asks for the protocol in one section. The other gives scenarios and we must use our knowledge of the protocols in those scenarios.

What I meant was that I don't know why they implemented these protocols. That is not part of understanding the protocol. I hope that this clears it up.

Again, sorry for miswriting that sentence. My soggy brain from head cold is starting to get to me. The fact that spellcheck is writing more than me tells me I should maybe take some cold medicine and go to bed. :sad4:

[paramedicmike]

What I meant was that I don't know why they implemented these protocols. That is not part of understanding the protocol. I hope that this clears it up.

Unfortunately, it doesn't clear anything up. And, based on this, Dust's questions still stand.

If you understand the protocols you should know why they're there in their current form. So you've just contradicted yourself.

But maybe because you're sick? Hope you feel better. Being sick sucks.

-be safe

[scratrat]

There is so much more to it than just the cost of the morphine. Drug seekers have an enormous impact on the costs to society (though I cannot speak for the system in the UK, only in the US). Who do you think pays for the ER visits for all of these people? Most of them will have medicaid (which the taxpayers pay for) or no insurance (the hospital will then pass the costs on to those who can/will pay their bills). Then there is the impact they have on the ER itself. They take up a bed that could be used by a person who really needs it. They take up the time and resources of the doctors, nurses, tech, etc that take care of them. When they call an ambulance they are taking up a ambulance that could be used by someone who truly needs it (and they likely will not pay for it). The US healthcare system is busting at the seams and is ready to collapse. These people are only making the situation worse. Their impact is much more severe than just the cost of the vial of morphine.

I am not saying not to treat people for pain (read some of my previous posts and you will see I advocate just the opposite), but when you have been in the field long enough you can spot BS coming through the door. I explain to these people that the ER is an inappropriate place to treat their chronic pain problems. I also tell them that it would be inappropriate for me to treat their chronic pain with the 4mg of Dilaudid (which I feel is one of the worst drugs ever created) that they ask for. So, while it may not seem like a big deal to give a drug seeker their hit once in a while, keep in mind that there is a much larger picture than what you have to deal with in the back of the of the ambulance.

I'll step off of my soapbox now and return you to your previously scheduled thread.

Thank you.

For the love of God, thank you.

[theotherphil]

There is so much more to it than just the cost of the morphine. Drug seekers have an enormous impact on the costs to society (though I cannot speak for the system in the UK, only in the US). Who do you think pays for the ER visits for all of these people? Most of them will have medicaid (which the taxpayers pay for) or no insurance (the hospital will then pass the costs on to those who can/will pay their bills). Then there is the impact they have on the ER itself. They take up a bed that could be used by a person who really needs it. They take up the time and resources of the doctors, nurses, tech, etc that take care of them. When they call an ambulance they are taking up a ambulance that could be used by someone who truly needs it (and they likely will not pay for it). The US healthcare system is busting at the seams and is ready to collapse. These people are only making the situation worse. Their impact is much more severe than just the cost of the vial of morphine.

I am not saying not to treat people for pain (read some of my previous posts and you will see I advocate just the opposite), but when you have been in the field long enough you can spot BS coming through the door.

Yep, exactly the same happens here in the UK. My point is I don't worry about medicating the 1 seeker in a hundred patients that I see. I cannot say that somebody isn't experiencing pain....only the patient can tell me that. If they say they have got pain, then they get pain relief in whatever form I feel necessary. Control of pain is important not only for humanitarian reasons but also because it may prevent deterioration of the patient and allow better assessment. Sure, they may be lying through their teeth or I may have my doubts about a person but at least I can say, hand on heart, that all my patients get adequate pain relief. As soon as you start becoming selective about who gets pain relief, innocent patients are going to lose out because you don't believe them.

Pain is a complex experience that is shaped by gender, cultural, environmental and social factors, as well as prior pain experience. Thus the experience of pain is unique to the individual. It is important to remember that the pain a patient experiences cannot be objectively validated in the same way as other vital signs. Attempts to estimate the patient’s pain should be resisted, as this may lead to an underestimation of the patient’s experience. Several studies have shown that there is a poor correlation between the patient’s pain rating and that of the health professional’s, with the latter often underestimating the patient’s pain. Instead, Ambulance Clinicians need to seek and accept the patient’s self-report of their pain. This is reinforced by a popular and useful definition of pain: “pain is whatever the experiencing person says it is, existing whenever he/she says it does". - (Joint Royal Colleges Ambulance Liason Committee 2006)

I explain to these people that the ER is an inappropriate place to treat their chronic pain problems. I also tell them that it would be inappropriate for me to treat their chronic pain with the 4mg of Dilaudid (which I feel is one of the worst drugs ever created) that they ask for. So, while it may not seem like a big deal to give a drug seeker their hit once in a while, keep in mind that there is a much larger picture than what you have to deal with in the back of the of the ambulance.

People usually ring an Ambulance because they have an acute problem which may be an acute exacerbation of a chronic illness. Having chronic pain doesn't mean that they don't deserve immediate pain relief before stabilisation of their condition and a review of their treatment plan and medication.

Here in the UK, we are totally autonomous from the hospitals. We don't work under an extension of a physician's licence, we are a licenced practitioner in our own right. Yes, we do keep in mind the bigger picture of what will happen at the hospital, but it has no real influence on what interventions I perform pre-hospital. I assess and treat my patient on how they present at the time of my assessment (and re-assessment). It is of no concern to me what happens once I hand over.

[scratrat]

People usually ring an Ambulance because they have an acute problem which may be an acute exacerbation of a chronic illness. Having chronic pain doesn't mean that they don't deserve immediate pain relief before stabilisation of their condition and a review of their treatment plan and medication.

Wow. I wish that were the case here. I can't say it doesn't happen, but rarely have I ever had someone who had an "exacerbation" of a chronic illness. I've had a few, but most people I've seen with chronic pain conditions, state "its been going on for weeks" and they "just can't take it anymore". Apparantly the scripts for vicodin, oxycodone, oxycontin, morphine patches, and so on, aren't doing the trick. See, when some one shows me their medication list, and it includes 5 or more narcotics, I'm not going to give pain control, at least 95% of the time I'm not. Call me what you want, but I'm not doing it. If something changed, or its a new injury, maybe. I'm not giving pain meds to someone with back problems (or whatever), who has already been prescribed 5 different narcotics. Not to mention the potential for side effects when mixing all those happy little pills.