Question about narcotics and allergies

Epi-do

Epi-do

I see dead people
Messages
1,947
Reaction score
9
Points
38
Recently, I had a run on an elderly lady that had fallen and was having lower back pain. She appeared to be in significant pain, and I was willing to give her fentanyl. I asked her about allergies and found out she was allergic to morphine and codiene. When asked what type of reaction she has, she stated she breaks out in hives and has resp distress.

Because of her allergy, I was hesitant to give her the fentanyl. I explained to her that it was in the same drug class as the drugs she was allergic to and I wanted to call the hospital and consult with a doc before giving it to her. She opted to not have the med, rather than risk having a reaction to it.

Granted, I did have benadryl and epi available to treat an allergic reaction, were she to have one. I just wasn't comfortable with risking that without talking to a doc first. Since the patient opted to not have the pain med, I never did call and talk to the doc though.

I wanted to ask about it when we got to the ER, but they were super busy so I didn't get a chance to talk with any of the docs. My question is, what would others have done? Would you have given the fentanyl? Would you have contacted med control first? I guess I am just looking for confirmation that I was thinking along the right path when thinking I should check with a doc first, given her other allergies.
 
Last edited by a moderator:
Fentanyl is an opiod, and works on the same opiod receptors in the brain that morphine and codeine do. However, it is a fully synthetic opiod made from constituent parts whereas morphine and codeine are found naturally in the opium poppy. There are also semisynthetic opiods like heroin, which is an esterfied molecule of morphine. Anyway, the point is that fentanyl is a different type of drug than morphine and codeine, and your patient may have tolerated it better since it would have different metabolites than other opiods, which may have caused the reaction. Personally I would not have given the drug, partly because she's not going to die of back pain, and also because I don't have the luxury of giving narcotics here on standing orders.
 
I'd probably hold off on the meds and place a blanket roll under the patient's knees.
 
I would had held off as well. Synthetic or not, as a close generation of medication I rather not risk it unless I could closely monitor and have time to be prepared to treat an adverse reaction. There is nothing like treating a reaction, especially after the patient informed you she could be allergic to the medication. Use another or as you did withhold for better options.

R/r 911
 
As mentioned, fentanyl is structurally different from morphine, as are it's metabolites and it is highly unlikely that it will cause a reaction just because morphine or codeine do. There is nothing wrong with checking with the doc, however I would have gone ahead and treated the patient (with her consent obviously, although I would have made sure she understood that there was very little chance of a reaction occuring)

I have to say though that I am alarmed that people will withhold pain relief because 'it's not going to kill them' or would just go with a bit of a old blanket roll and you'll be ok dear. :unsure:

Very little that we do in the pre-hospital arena has as great an impact on a patient than providing adequate pain relief. It is an absolute imperative that we treat patients humanely and appropriately. Pain doesn't just happen when we have a big car smash or catch fire or have an MI and we should actively and aggressively persue analgesia in all patients regardless of the cause of their.

Acute pain when left untreated leads to many serious, ongoing systemic problems and greatly increase the risk of developing chronic pain disorders. Hence the aggressive management of pain both pre and post-op and the specialization of anesthetics into pain management.

Elderly patients (and the young) are at significantly greater risk of oligoanalgesia due to issues in the perception and reporting of pain. It doesn't mean they don't feel it, just that they don't complain of it.

It is widely recognised that pain relief in acute care (both in the ER and in the ambulance) is something that is often neglected. Progressive services now include reductions in pain scores as an important key performance indicator for their service. All paramedics should be aware of and able to use pain rating scales to ensure that they are appropriately assessing and treating pain of any cause in any patient including the young, the old, the insane, anyone.

Back pain, leg pain, abdo pain, whatever; it doesn't matter what causes the pain, what matters is that we make it go away.
 
Smash said:
I have to say though that I am alarmed that people will withhold pain relief because 'it's not going to kill them' or would just go with a bit of a old blanket roll and you'll be ok dear. :unsure:

Very little that we do in the pre-hospital arena has as great an impact on a patient than providing adequate pain relief. It is an absolute imperative that we treat patients humanely and appropriately. Pain doesn't just happen when we have a big car smash or catch fire or have an MI and we should actively and aggressively persue analgesia in all patients regardless of the cause of their.

Back pain, leg pain, abdo pain, whatever; it doesn't matter what causes the pain, what matters is that we make it go away.
Click to expand...

Agreed, just remember that all systems are different. 'Round here I carry morphine, midazolam and diazepam, and morphine is an online order. I won't hesitate to call for a STEMI patient or an isolated long bone injury, but I can't go off trying to give my patient a narcotic every time grandma falls down. If I called for narcotic orders every time I had a patient in pain I would soon be viewed as "that guy", and no one would take me seriously. Also, while you don't have to be an orthopedist to see a patient has a compound fracture, I think some complaints deserve an M.D. level assessment before analgesics are given.

Now if I had some N2O, or toradol, that would make life a lot easier.
 
emtbill said:
Agreed, just remember that all systems are different. 'Round here I carry morphine, midazolam and diazepam, and morphine is an online order. I won't hesitate to call for a STEMI patient or an isolated long bone injury, but I can't go off trying to give my patient a narcotic every time grandma falls down. If I called for narcotic orders every time I had a patient in pain I would soon be viewed as "that guy", and no one would take me seriously. Also, while you don't have to be an orthopedist to see a patient has a compound fracture, I think some complaints deserve an M.D. level assessment before analgesics are given.

Now if I had some N2O, or toradol, that would make life a lot easier.
Click to expand...

So pain is only painful if you have broken a long bone or are having a STEMI? If it was your grandma who fell down, injuring her back, fracturing her NOF or busting her pubic rami, would you A) want her to be in pain or B) not want her to be in pain?

What exactly is "that guy"? The guy who cares that his patients recieve optimal treatment? Or the guy whose ego and reputation come first?

Which complaints 'deserve' to have no pain relief? Abdo pain? Back pain? Fractures?

In what way does the patient benefit by being in pain before the doctor sees them?

I guess I'm lucky in a way. If I leave a patient at hospital with inadequate analgesia the Drs and the service will be asking me why I didn't bother treating them, I'll get written up and possibly lose my authority to practice. It's like not giving ASA to chest pains; utterly unthinkable! Fine by me, it means patients will get what they need.
 
Smash said:
So pain is only painful if you have broken a long bone or are having a STEMI? If it was your grandma who fell down, injuring her back, fracturing her NOF or busting her pubic rami, would you A) want her to be in pain or B) not want her to be in pain?

What exactly is "that guy"? The guy who cares that his patients recieve optimal treatment? Or the guy whose ego and reputation come first?

Which complaints 'deserve' to have no pain relief? Abdo pain? Back pain? Fractures?

In what way does the patient benefit by being in pain before the doctor sees them?

I guess I'm lucky in a way. If I leave a patient at hospital with inadequate analgesia the Drs and the service will be asking me why I didn't bother treating them, I'll get written up and possibly lose my authority to practice. It's like not giving ASA to chest pains; utterly unthinkable! Fine by me, it means patients will get what they need.
Click to expand...

I can totally see what Bill was eluding to as "that guy". It's an inappropriate stigma when you administer meds rationally and appropriately, but I've been with many services whom carry that overall attitude. Perhaps not at the levels of management or medical authority (pssst billing too...), but it is prevalent.

Smash, I'm envious of your systems unwillingness to accept the "that guy" mentality!
 
If the medical director does not trust his people are educated enough to determine proper use of medication he should not allow them to work under his license. By requiring contact of medical control you delay care and you actually cause people to suffer because the medic is ashamed to make the call as they don't want to be "that guy". If you choose to work in a mother may I system don't make a patient suffer because of your pride, make the call.
 
I have both observed and read that many provider are way to conservative with giving their patients analgesia in the field. Should ALS be more aggressive with pain management? I think so.
 
I think some complaints deserve an M.D. level assessment before analgesics are given.
Click to expand...

A good MD should be able to perform his assesment with or without the patient in pain, your patient should not be left in pain! Epi withheld drugs because of possible allergic reaction, which was the right course of action. No need to put the patient in anaphylaxis on top of a fracture.
 
Sasha said:
A good MD should be able to perform his assesment with or without the patient in pain, your patient should not be left in pain! Epi withheld drugs because of possible allergic reaction, which was the right course of action. No need to put the patient in anaphylaxis on top of a fracture.
Click to expand...

Why not? Think about it he could practice his advance airway skills possibly,:ph34r:
 
medic417 said:
Why not? Think about it he could practice his advance airway skills possibly,:ph34r:
Click to expand...

I hope you are not mocking epi, she's great and very caring.
 
Sasha said:
I hope you are not mocking epi, she's great and very caring.
Click to expand...

Note the smiley. Was being sarcastic, never actually cause patient to suffer so you can play.

Yes EPI did right. Never harm your patient. Epi explained the risks and patient agreed to wait. Very good way to handle situation. Too many fail to even consider the patients feelings in regards to risks. So yes I applaud EPI for communicating with patient and not harming patient.
 
A good MD should be able to perform his assesment with or without the patient in pain
Click to expand...

I agree... the old adage of don't provide analgesia until evaluation by a physician is no longer real applicable. This used to be more of the case a long time ago where physicians had to rely solely on physical exam findings to make a more accurate diagnosis without the advantage of todays technology.

Today, with the universal availability of CT Scans and MRI, the physician can see inside and see whats going on. The current literature advocates that even for abdominal pain, patients should be given pain relief in the field and providers should start being more aggressive in relieving their patients pain prior to ED arrival.
 
I am glad to see that others would have with held analgesics for this particular patient. We are very fortunate that are medical director has been pretty free with our protocols for pain relief, compared to other services around us. We can give up to a total of 300 mcg of fentanyl before having to call for orders for additional meds. We are allowed to give adults 50-100 mcg every 3-5 minutes, so I have rarely had to call for orders for additional meds due to short transport times.

My only wish is that we also carried some sort of non-narcotic analgesic for situations such as this. This particular patient rated her pain 4/10, however she would grimace and guard every time she tried to move. She was moving very cautiously and slowly as well, being insistant on trying to move herself rather than having us do it. We did help her to her feet and then used a stair chair to get her to our stretcher.

I have been teased from time to time for being "that" provider when it comes to pain management, however, if it makes my patient more comfortable and my job to care for them easier as a result, I don't really care.
 
Like Epi said, her medical director is a little more liberal with allowing them to give pain meds. I'm not saying that patients complaining of pain don't deserve prehospital analgesics, but I have to be more judicious with who gets them. I really need objective evidence before I consider doing it. I guess that's a downfall of where I work. A lot of services around us don't even carry controlled substances, so we're fortunate to have what we do. There's a lot of red tape every time I open the narcotic box (they're kept seperate from the other drugs)...it's an online order, there's a card in the box accounting for every vial of drug that has to be filled out, signed and witnessed by the nurse and MD when you waste the rest of the med in the sink at the hospital, then I have to call my captain to get into the safe and restock the box. What this boils down to is that there's so much accountability for the meds that only the sickest patients get them. The patient who complains of back pain over the past 4 days but waits until today to call me then walks into my ambulance can wait the 7 minutes it takes to get to the hospital for relief.
 
emtbill said:
What this boils down to is that there's so much accountability for the meds that only the sickest patients get them.
Click to expand...


So because it makes you do more work you will make a patient suffer? That is just wrong and non professional.

All of us have lots of extra documentation when using narcotics, or if not at some point it will bite you in the rear.
 
It's not me, it's the system. I don't mind the extra work but I wouldn't get orders for lower back pain after a fall. I can only do what the MD will allow me to do.
 
A good many areas allow for pain meds in the field pre-radio. No sense in a patient being in pain when we can often do something. In the case of this lady, she has a history with meds. Barring a long ambulance transport, waiting...or maybe Toradol seems most prudent.
 
You must log in or register to reply here.
Back
Top