Physicians' Impression of Pre-Hospital Pain Management

[zmedic]

It's always a good idea to keep in mind who is chewing you out. At some level 1 trauma centers they are training residents, including residents from fields other than EM (IM, ortho etc). So sometimes the "docs" you are getting yelled at don't know a ton about EM. On the other hand if you are getting chewed out by the chair of the department/experienced attending I'd really think about what they said and talk it over with your medical director to make sure the protocols are clear. If you are following protocols and the ED doc is chewing you out that's when it's time for the docs to fight it out.

 

[redcrossemt]

It's always a good idea to keep in mind who is chewing you out. At some level 1 trauma centers they are training residents, including residents from fields other than EM (IM, ortho etc). So sometimes the "docs" you are getting yelled at don't know a ton about EM. On the other hand if you are getting chewed out by the chair of the department/experienced attending I'd really think about what they said and talk it over with your medical director to make sure the protocols are clear. If you are following protocols and the ED doc is chewing you out that's when it's time for the docs to fight it out.

After this incident, I spoke with a PA-C who works full-time in EM as well as the physician director of the ED. Both sided with me, and both also brought up that the literature supports pain management for these patients. They also both noted that it was within my protocols to provide such.

 

[rhan101277]

After this incident, I spoke with a PA-C who works full-time in EM as well as the physician director of the ED. Both sided with me, and both also brought up that the literature supports pain management for these patients. They also both noted that it was within my protocols to provide such.

I wouldn't feel bad about it at all. Some people have personal issues and take it out on whomever. One of the advantages of pre-hospital care is the ability to stop pain or mitigate it. If they are in pain and you deem it necessary, it is your job to provide the best care, which includes pain management. Some people are just grumpy people.

 

[jason152318]

This seems to be a common problem in the EMS system I work in as well. But as said by others, the hospitals assessment shouldn't be ruined by pain management pre-hospital. There are other tests and procedures that they will eventually have to do to come up with a final diognosis anyway, and in most cases the pt's arent pain free upon hospital arrival. So bringing a pt from a 10-10 pain down to a 3-10 pain isnt going to ruin the assessment for example, and eventually the meds will stop doing there job. As long as you are following protocol, that is really what matters.

 

[sdadam]

Here is some research supporting what most everyone has said.

Pain management has no effect on the accuracy of diagnosis. And withholding it is arcane and poor medicine.

http://www.ahrq.gov/CLINIC/ptsafety/chap37a.htm

In fact according to one study (and this is just one study, I realize we should never change practice based off a single study, regardless of the results) ended up having a significantly higher rate of miss diagnosis in the PT who didn't receive pain control.

Attard et al6 found no difference in localization of physical signs, and no difference in the surgeon's diagnostic confidence or management decision (to operate or to observe) between the 2 groups (opioids vs. placebo). The decision to operate or to observe was incorrect in 2 patients in the opioid group (4%) and in 9 patients in the placebo group (18%).

The above link reviews five different studies, all of which had similar outcomes.

When it comes to the way the Dr. treated you, i would respectfully disagree with her, if she turned her back on me I would kick her in the balls.

(kidding, just so were all clear I wouldn't actually kick a Dr. in her non-existant balls)

Adam

 

[mycrofft]

Human factor at work.

There are three times a doctor will take you aside...to save you embarassment, to spare the patient or family extra anxiety (or grounds to sue), or to get you away from others and whittle at you, maybe in a fashion her/his peers are fed up with. If the family isn't there, you decide if you are being tutored, or cut out of the herd for a little torment. Even if you are being chewed on a little sadistically, there may be a point to learn if not agree with or adopt.
Me, I cut in, establish if I'm being Sadimized (run over by a Sadist), establish if I'm truly in trouble or not, then either walk away or stop and talk for a bit.

 

[EricCSU]

This very topic was the topic of a previous research paper that I wrote and consequently turned into a presentation. I would be happy to email it to you if you provide your email address in a PM.

As far as your question, here are my thoughts:

Patient assessment is actually much easier following appropriate analgesia (this is supported by mounds of research as well as anecdotally). What was previously diffuse abdominal pain with a patient writhing is not tenderness concentrated to a very defined area.

Effective analgesia is one of the few times we can make an actual difference in someone's life. Pain is not just a nuisance, it is a significant problem which must be treated.

Eric

P.S. Short of posting the entire paper in this forum, here are my references:

[1] Position Paper: Prehospital Pain Management. National Association of EMS Physicians. Prehospital Emergency Care. October-December 2003. 482-488.
[2] Why Don’t We Do a Better Job of Treating Pain?. Bryan Bledsoe, DO. http://www.bryanbledsoe.com/pdf/handouts/PowerPoint/Pain Management.ppt#256,1,Why Don’t We Do a Better Job of Treating Pain?
[3] Pain Management in the Prehospital Environment. McManus MD, Sallee MD. Emergency Medical Clinics of North America. 2005. 415-431.
[4] Prehospital Pain Management: Current Status and Future Direction. Hennes MD, Kim MD. Clinical Pediatric Emergency Medicine. 2006. 7:25-30.
[5] Pain Medication Administration in Pediatric Trauma Patients with Long Bone Fractures Before Emergency Department Arrival. Mader MD, Letourneau MD. Annals of Emergency Medicine. October 2004. 44.
[6] Inadequate Analgesia in Emergency Medicine. Rupp MD, Delaney MD. Annals of Emergency Medicine. April 2004. 494-503.
[7] Refusal of Base Station Physicians to Authorize Narcotic Analgesia. Gabbay MD, ****inson MD. Prehospital Emergency Care. July-September 2001. 293-295.
[8] Simplyifying Prehospital Analgesia. Bledsoe DO, Braude MD, Dailey MD, Myers DO, Richards MD, Wesley MD. Journal of Emergency Medical Services. July 2005. 57-59.
[9] Changing Attitudes About Pain and Pain Control in Emergency Medicine. Fosnocht MD, Swanson MD, Barton MD. Emergency Medicine Clinics of North America. 2005. 297-306.
[10] The Epidemiology of Pain in the Prehospital Setting. McLean MD, Maio MD, Domeier MD. Prehospital Emergency Care. October-December 2002. 401-405.
[11] Few Emergency Medical Services Patients with Lower-extremity Fractures Receive Prehospital Analgesia. McEachin BSN, McDermott EMT-P, Swor DO. Prehospital Emergency Care. October-December 2002. 406-410.

 

[COWSskateGOOD]

I treat my patients how I would treat my family member, or by the golden rule : Treat Others as how you wish to be treated.... What would I want in that scenario if it were me in pain.

Something I have learned: Always err on the side of the patient...

 

[firetender]

I just want to say I think this is a really potent and exemplary thread that really, REALLY informs the readers and gets them to think as well.

BRAVO!

...and, then, putting myself in the head of today's typical physician, how about this simple, malpractice-related formula:

Abdominal pain = Surgery = Consent.
------------------(divided by) ----------- ...............= LIABILITY FOR
Meds prior to signing = questionable consent ................POOR OUTCOME

 

[rhan101277]

I'm still learning, but most of the trauma patients that come in don't have pain meds on board. I know most are not stable, but I think the ones that have stable blood pressure and has been trending stable should get at least 4mg morphine.

Like this one guy that came in with bilateral gunshot wounds to the legs. Stable patient but in pain. We are there to treat pain, but sometimes its a double edged sword because you gotta worry about BP.

 

[AnthonyM83]

Any chance it was the part about being able to join the committee that decides protocols? I honestly have no idea how it was said, but usually when discussions get to that point, one has moved away from the actual topic...

 

[redcrossemt]

Any chance it was the part about being able to join the committee that decides protocols? I honestly have no idea how it was said, but usually when discussions get to that point, one has moved away from the actual topic...

It's an interesting thought. However, I only got to the point of saying that when the physician said my protocols were "poorly written" and shouldn't include pain management for abdominal pain.

 

[grich242]

It's an interesting thought. However, I only got to the point of saying that when the physician said my protocols were "poorly written" and shouldn't include pain management for abdominal pain.

Remember that the protocols we work under are relitavely new in the sense that only 6 years ago we were usualy unable to get orders for anything with many doc's in the system stating on more than on occasion that we would never get orders for ANY reason... most of our tretments were post radio... that being said the protocols and attitudes of the docs at area er's have come a long way.

 

[Veneficus]

We are taught in school pain management doesn't affect the ability to dx a surgical abdomen and to aggresively manage pain.

If you really wanted to be a smart A** you could ask how pain control intereferes with a CT scan, since in the US nobody I have heard of is going to rule out anything significant without a scan.

 

[redcrossemt]

Remember that the protocols we work under are relitavely new in the sense that only 6 years ago we were usualy unable to get orders for anything with many doc's in the system stating on more than on occasion that we would never get orders for ANY reason... most of our tretments were post radio... that being said the protocols and attitudes of the docs at area er's have come a long way.

My point is that we need to progress further! It's a sad day in my book when a physician is withholding pain medication for abdominal pain, when the paramedics know the research is there to support it and have the protocols to do it.

 

[redcrossemt]

We are taught in school pain management doesn't affect the ability to dx a surgical abdomen and to aggresively manage pain.

If you really wanted to be a smart A** you could ask how pain control intereferes with a CT scan, since in the US nobody I have heard of is going to rule out anything significant without a scan.

Thank you.

Oh, I understand why we shouldn't manage pain now! Obviously opiates block x-ray radiation and prevent good imaging studies!

 

[JPINFV]

Thank you.

Oh, I understand why we shouldn't manage pain now! Obviously opiates block x-ray radiation and prevent good imaging studies!

I believe he was being sarcastic with that comment. As in ask the attending how exactly opiates affects cat scans.

 

[redcrossemt]

I believe he was being sarcastic with that comment. As in ask the attending how exactly opiates affects cat scans.

LOL and I was trying to be sarcastic back. Maybe I should've winked.

 

[JPINFV]

::whistles::

 

[Aidey]

So often now ambulances have one, maybe two methods of pain control. Nearly always an opiate. Giving certain abdominal issues certain opiates can make them worse (namely bowel obstructions). It isn't always about diagnosing the problem, but making sure the pain control isn't going to make the problem worse. It would be nice if we were able to have more options so that we weren't doing this "one size fits all" pain control.

I think if we were able to do that we could have more progressive protocols about treating things like abdominal pain, back pain, and severe headaches. I would also like to see more protocols allowing for a skeletal muscle relaxants in dislocation cases.