Physicians' Impression of Pre-Hospital Pain Management

[usalsfyre]

Anyhow I get to ER and I am told by physician that it was "a little over the top" to start an IV and give morphine.

Actually, he's really probably right. EMS suffers from dearth of pain management options. It's either nothing, or killing a flea with a shotgun (IV narcs). If I ruled the world, you'd see varried options for EMS, methoxflurane or entonox (both not approved for US use), PO and IV NSAIDS and APAP, PO narcs, IV narcs mixed with benzos and ketamine.

Turns out pt had been prescribed plenty of pain meds and was probably drug seeking. I refuse to get into the mind set that every patient that I encounter who is in pain can just tough it out till the hospital, since they are probably lying to me anyway. I am not there to pass judgment, they initiated EMS system so I am there to help.

Maybe I should bring one of those magic 8 balls and use it after I ask each question to determine whether my pt is lying or what not.

The correct attitude, and like I said, unfortunately we've got to continue to kill fleas with shotguns.

Physician ordered IV taken out and pt sent to waiting room in wheelchair. Physician was not irate or anything but still, I am going to continue to follow protocols and if pain management is warranted I am going to do so.

Fortunately the physician was willing to do this. Not an inapproprite way of opperating, but one many hospitals are uncomfortable with due to liability concerns. Narcotics are not nearly as dangerous as their made out to be in emergency medicine, but they're still seen as the boogey man by many.

 

[johnrsemt]

It isn't EMS's job to decide if the patient is a drug seeker or not: some ED's give scripts for 2-3 days of pain meds with orders to patient to follow up with Ortho doc or family doc; and they can't get into see the doc for 5-10 days: esp if ED was Friday and doc isn't open til monday to even call.
So when we get called back to house on Sunday evening because they are out of meds and they are in pain: I give them pain meds to make them comfortable.

 

[rhan101277]

I think the doc was frustrated because the pt did not follow up. Thanks for the replies. If we were allowed to give PO meds for pain (Lortab etc.) I would have done that for this particular instance.

 

[bigbaldguy]

Are there any EMS systems (international) that allow EMS to prescribe narcotic PO meds to patients.

Sorry I should clarify that. By prescribe I mean give the patient say a 3 day supply of meds. I know in some systems pre hospital folks can do something similar with antibiotics and such.

 

[rhan101277]

Wake County, NC. allows PO meds for pain <6/10. No scripts though.

 

[jwk]

Are there any EMS systems (international) that allow EMS to prescribe narcotic PO meds to patients.

Sorry I should clarify that. By prescribe I mean give the patient say a 3 day supply of meds. I know in some systems pre hospital folks can do something similar with antibiotics and such.

Hmmm, that doesn't sound right, narcotics, antibiotics, or otherwise. That would be called dispensing, and in most states that means pharmacist-only with a few exceptions.

 

[WelshMedic]

I agree that prehospital analgesia is very important and that patients need to recieve adequate analgesia.

That said, lets say this patient was 50kg (50mcg of fentanyl at 1mcg/kg) is equivalent to 5mg of morphine. If she was 50g at this guy'd dose of 1.5mcg/kg that's like 7.5mg of morphine.

If this were me .... I might give her oh, 2mg and titrate up to maybe 5.

I can sort of see where this doc might be a bit pissed I mean was this patient spun off into lalaland or did she tolerate the fentanyl quite well? I mean in general I'll that physicians who think ambo's should not be giving pain relief are idiots but if ambo gets thier patient so wasted they can't participate in exam or treatment then yeah, fair enough.

I think you make a good point here. In a healthy 26yr old then 1.5mcg/kg shouldn't be a huge dose, but it also depends on their build and PMH. I would start at 1mcg/kg and titrate up from there.

Carl

 

[FFEMT427]

Proper use of MS

I agree that prehospital analgesia is very important and that patients need to recieve adequate analgesia.

That said, lets say this patient was 50kg (50mcg of fentanyl at 1mcg/kg) is equivalent to 5mg of morphine. If she was 50g at this guy'd dose of 1.5mcg/kg that's like 7.5mg of morphine.

If this were me .... I might give her oh, 2mg and titrate up to maybe 5.

I can sort of see where this doc might be a bit pissed I mean was this patient spun off into lalaland or did she tolerate the fentanyl quite well? I mean in general I'll that physicians who think ambo's should not be giving pain relief are idiots but if ambo gets thier patient so wasted they can't participate in exam or treatment then yeah, fair enough.

Do you realize that a standard low end dose of MS is 0.1 mg/kg and therefor if you start out at 2mg for a 50kg pt you are giving less than half of a suggested low end dose.
Its not all our fault in the field we are fighting through years of dogma that treating pain in the field will somehow slow down docs in the ED. That is a falsehood (Well if you have sharp docs in your ED).
Think about the thing that we can help our pt.'s out with the most.
What percentage of pt.'s do we put crics in? How many do we cardiovert? But how many pt.'s have you had that have pain. Therefor it is an area where we can cause alot of good.
1.5 mcg/kg of fent Bravo
There is an equation that I did not make up but will pass on from now till the end of my career it is severe pain + 2mg Morphine = servere pain.

 

[KellyBracket]

I would just ask that the OP make ever-so-slight an adjustment to the title. Since it was one physician who made the comment, perhaps the title shoul be something more like "This One Physician's Impression..."

A few of us generally like the idea of aggressive prehospital analgesia. Frankly, I wouldn't mind seeing a few more"inappropriate" morphine doses given in the field, since it would probably mean that a heck of a lot more "appropriate" doses were also being given!

 

[daj72]

First point: Tough luck to the physician. You're working under your med directors license, not hers. If she doesn't like how something is done and it's in accordance to what your MD accepts, tough noogies, it's not her call. Doesn't want an IV? Start one if you deem necessary. If she keeps complaining, ask her if she's willing to be co-named on the lawsuit for not providing an IV to someone who needed it.



As far as pain control for abd pain, I've spoken to a few Docs and PAs on the matter and they are all pretty much in agreement: Pain meds should not make or break their diagnosis, and should not slow down their assessment. If you deem your pt needs pain control, then do pain control.

What this dude is saying

 

[Handsome Robb]

A few of us generally like the idea of aggressive prehospital analgesia.

You can include me in that statement, along with my medical director.

 

[jjesusfreak01]

Wake County, NC. allows PO meds for pain <6/10. No scripts though.

As a WakeEMS employee, i'll mention that Tylenol is given only very rarely, and generally for patients with very minor injuries. Severe pain from any condition for which surgery will not be required will get Toradol, and if there is any chance of surgery in the pts future, Morphine or Fentanyl.

 

[KellyBracket]

Interesting decision tree for analgesics. I'm not sure that EMS should have the burden of guessing whether surgery will be indicated before administering morphine. Is this the protocol, or your experience?

As a WakeEMS employee, i'll mention that Tylenol is given only very rarely, and generally for patients with very minor injuries. Severe pain from any condition for which surgery will not be required will get Toradol, and if there is any chance of surgery in the pts future, Morphine or Fentanyl.

 

[Fish]

Patient Summary: 26 y/o female with worsening left flank pain over the past 3 days. It has been a 2-3 out of 10, just kind of achy; but this morning is a "20" out of 10, woke patient out of her sleep, and she couldn't get back to sleep because of the pain. Patient was tachycardic, tachypneic, wincing, and generally appeared to be in distress. Interventions included 1.5 mcg/kg of fentanyl IV. Our transport time was about 8 minutes.

After patient care had been transferred and report given to nursing staff, the ER physician took me aside and asked me why I had given fentanyl to this particular patient. I reiterated the story above, emphasizing that the patient said she was in severe pain, and appeared to me to be in distress. I also reiterated our pain management protocol, and that the pre-hospital standard of care now includes pain relief. The physician seemed very upset with this, stating that it impaired her assessment of the patient, and that the "ride over here was only 8 minutes" and the patient could wait for pain medicine. She even said that us giving pain medicine makes their "2mg of morphine seem not so great" to the patient.

I tried to answer all of her concerns to the best of my ability. I emphasized the short half-life of fentanyl, the results of my initial physical exam that were completed before pain medicine, that 8 minutes of pain is still 8 minutes of pain, and that the effectiveness of their morphine should only be based on the patient's pain relief. I also tried to bring up the fact that our protocols (for the entire regional system) are based on ER physician recommendations from all of the area hospitals and that she could participate in the working group if she'd like to make recommendations.

In any case, the physician ended up walking away from me in mid-conversation, with nothing resolved.

I have worked with lots of partners who show resistance to treating pain (you all know the type... "the patient doesn't deserve the pain meds", "it's a short trip", etc...) but I have yet to experience this resistance with physicians or hospital staff.

My question to everyone is, does pain medicine actually interfere with physician assessment, should we not be providing pain relief to unknown abdominal/side pain patients, and have you had physician resistance to pain management protocols? And any advice for handling this physician (who has told us before to not start IVs on patients, even those in need of ALS, so they can go out to external triage - aka 'the lobby')?

If your patients in Pain, then relieve the pain(It is your job) If they need an IV start an IV(its your job) If that MD has a problem with this, well then I think your Medical Director should be made aware so that they can have a chat.

 

[Shishkabob]

There's few things I can argue with a physician on where 8 years vs 2 years education doesn't matter... analgesia is one of them. :lol:

 

[jjesusfreak01]

Interesting decision tree for analgesics. I'm not sure that EMS should have the burden of guessing whether surgery will be indicated before administering morphine. Is this the protocol, or your experience?

Experience. We don't use Toradol very often at all. Its usually, "suck it up" or Morphine...

 

[redcrossemt]

OP: So what was it, kidney stone?

Sorry for the delay. I've been away from the forum, occupied with other things.

Indeed it was a kidney stone.

 

[redcrossemt]

There's few things I can argue with a physician on where 8 years vs 2 years education doesn't matter... analgesia is one of them. :lol:

True story. Sad to see that this post was revived! Things are in general better in our system now, a year later, with fairly widespread acceptance of prehospital pain management.

As far as dosing, our new protocols allow 1 mcg/kg fentanyl up to a total of 3 mcg/kg, and/or morphine 0.05 mcg/kg up to 20 mg. We also have midazolam available now, which we have used (post-radio) for painful procedures with great success.

 

[Bryan]

Hmmmm thanks for sharing this i really like ur post it was quite helpful quite interesting i got so many new things in this post u really have the knowledge thanks.........

 

[DV_EMT]

aslo, you have to consider a patients tolerance for pain as well as body weight...

I.E.... I have an OK pain tolerance, but for the most part, If I require pain meds from an MD, I usually request Vicodin with the standard 1-2 Q4-6 prn Pain. I usually need 2 of them to even feel any relief, and its because I can handle my meds (like my drinks) with ease. One vicodin does nothing to my pain level.

Personally, If i know someone isn't faking it and is in True Pain and shows signs/symptoms such as tachycardia/diaphorsis etc... why not help them out with something to make them more comfortable. (this doesnt include migrane and other "petty" problems).