Pain Management

[Masonicmedic]

I had a Pt 18 YOF about a two weeks ago with partial thickness burns to her left arm approx. 8% involving her upper arm , forearm,wrist and the back of her hand. Her HR was about 130 RR 28 shes in moderate distress from the pain. I was working BLS at the time and one of the paramedics says to me " we dont be treatin pain management" I replied with "REALLY" at which point the medics partner says he will ride with the patient. He gave her 2 mg of morphine and like magic her HR went down to 80 and she stopped cursing. After bringing her to her hospital of choice which was about 25 min. away i was returning to my truck and again the other medic was like "just to let you know we dont treat that". I just got in my truck and drove back to post. I must also add that the call went out 20 min before shift change. I just want to know other peoples input on this

[medicmade]

Ok someone does not know there protocals. He was most likely one of those medics who thought eveyone in pain was faking it and just wanted drugs. Here we are quick to get pain orders if we feel we need them.

[medicgoddess]

We carry those drugs for a reason and its not just so we look cool. If they need it-push it.

[kjrff23]

I agree, we have pain management protocols in RI. Burns and single system trauma are what it's intended for. When in doubt look it up.

[jdemaio]

In my system, we have standing orders for 0.1 mg/kg for morphine for pain management, we can call and get further orders, but this is what we have on standing order. I believe that there is not one medic in my department that would withold morphine for a severely burn Pt. Infact, we are highly encouraged to aggressively treat these Pt's pain.

In my opinion, if a medic who has the capability to treat the pain of a burnt Pt and does not, he is mistreating his Pt. With that said, there is no reason for a BLS crew to sit around on scene waiting for a medic for pain mgmt. It is NOT a life saving treatment and it should not be thought of like one. If you can get a medic to the Pt, great, but what the Pt needs is a burn ctr/trauma ctr. If you have one, use it, but just get the Pt to the darn hospital. Do not delay transport.

[anthonyt]

just get the Pt to the darn hospital. Do not delay transport.

When I was a basic, I believed in getting an ALS crew to an ALS patient... still do... If the hospital was 25 minutes away, it's likely you could get a medic to the patients side quicker, in most cases, I would imagine...

If that is the case then, I say good job, good thinking, get the patient relief quicker by getting them to a medic first then to the hospital. After all a 25 minute ride with a patient in distress such as this patient appeared to be is nothing short of torture. Cruel and inhumane...

It's not always in the patients best interest to just give em a taxi cab ride. Like I have said to my partner when he has said to me, "Dude, we're like 7 minutes from the ER, let's just go and let them do the iv, and drugs..." I said, well now, then we wouldn't really be providing ALS care then would we? We can either do OUR jobs, or let someone else do it for us." ALS care is about stabilizing the patient then transporting... not the other way around.

Just my .02 though.

[PSYCtest040]

If I'm on a basic truck and respond to this type of call then my plan is to minimize on scene time and treat while in route. If I can meet ALS before the hospital that's great, if not then it's straight to the trauma center. I'm not doing the pt much good by waiting for ALS to arrive.

[Masonicmedic]

Yea i forgot to mention we have a two tiered system in jersey so we got there like one min. ahead of the medics . they showed up as we were loading her on the cot

[codeblue603]

:glasses1:

i go by if it was may kid or someone that i care for what would i want the medic do? that would be he)) yes give them some thing for the pain, that is our job, this if you can per training and having it to give.


and that is all i have to say about that.

[medicgoddess]

No two teired system here. Just our ALS service and fire dept (of which most are ALS). So pain management enroute should happen. However, if we were teired and one of our BLS trucks delayed transport instead of going enroute and meeting a medic on the way-heads would roll I'm sure.

[jdemaio]

When I was a basic, I believed in getting an ALS crew to an ALS patient... still do... If the hospital was 25 minutes away, it's likely you could get a medic to the patients side quicker, in most cases, I would imagine...

If that is the case then, I say good job, good thinking, get the patient relief quicker by getting them to a medic first then to the hospital. After all a 25 minute ride with a patient in distress such as this patient appeared to be is nothing short of torture. Cruel and inhumane...

It's not always in the patients best interest to just give em a taxi cab ride. Like I have said to my partner when he has said to me, "Dude, we're like 7 minutes from the ER, let's just go and let them do the iv, and drugs..." I said, well now, then we wouldn't really be providing ALS care then would we? We can either do OUR jobs, or let someone else do it for us." ALS care is about stabilizing the patient then transporting... not the other way around.

Just my .02 though.
I'm not saying that you shouldn't treat a Pt's pain, what I'm saying is that there is no reason to sit on scene for 10 minutes, waiting for a medic when the hospital is 5 minutes away. OR try to meet the medic enroute to the ED. Pts need hospitals, pain management is not a life saving treatment, it is a comfort measure. If I remember correctly, there was a study done with NYC*EMS (I believe pre-FDNY) and the NYC voluntary EMS providers correlating the survivability of trauma patients when brought to the ED by cabs vs. being brought in by ambulance. (once again, if I remember correctly) The survivability of trauma Pts brought in by cab was significantly higher than brought in by ambulance. If the medic bus is not there by the time that the patient is packaged and in the ambulance, GO. It is preferred that these patients get pain meds, but no BLS crew should ever have to close the doors to their bus and think "hmm, alright, I guess we'll just wait for the medic." If the hospital is closer than the medic, go to the hospital, and either way, start moving toward the hospital while the medic is enroute. If he meets the BLS crew, GREAT, if not, at least the patient is in the hospital where the patient can be better treated.

Like I said before, my two jobs strongly encourage aggressive pain mgmt for burnt Pts. but in the event that a medic is not available (which is, fortunately, almost never) the patient should be rapidly transported to the ED.

If I were on the flip side and I was a heavily burnt Pt, I would want as much morphine as I could get, but not at the expense of getting to the hospital.

[anthonyt]

Well said sir.

[jdemaio]

Well said sir.
You're not serious are you?

[prncssmdc]

I'm not saying that you shouldn't treat a Pt's pain, what I'm saying is that there is no reason to sit on scene for 10 minutes, waiting for a medic when the hospital is 5 minutes away. OR try to meet the medic enroute to the ED. Pts need hospitals, pain management is not a life saving treatment, it is a comfort measure. If I remember correctly, there was a study done with NYC*EMS (I believe pre-FDNY) and the NYC voluntary EMS providers correlating the survivability of trauma patients when brought to the ED by cabs vs. being brought in by ambulance. (once again, if I remember correctly) The survivability of trauma Pts brought in by cab was significantly higher than brought in by ambulance. If the medic bus is not there by the time that the patient is packaged and in the ambulance, GO. It is preferred that these patients get pain meds, but no BLS crew should ever have to close the doors to their bus and think "hmm, alright, I guess we'll just wait for the medic." If the hospital is closer than the medic, go to the hospital, and either way, start moving toward the hospital while the medic is enroute. If he meets the BLS crew, GREAT, if not, at least the patient is in the hospital where the patient can be better treated.

Like I said before, my two jobs strongly encourage aggressive pain mgmt for burnt Pts. but in the event that a medic is not available (which is, fortunately, almost never) the patient should be rapidly transported to the ED.

If I were on the flip side and I was a heavily burnt Pt, I would want as much morphine as I could get, but not at the expense of getting to the hospital.

I concur. Excellent point. Just don't waste time calling for a medic unit is all I ask -- for the pt's sake.

[prncssmdc]

Pain management is the newest push at our company...I am glad it's being pushed finally. In fact, they are all in favor of trying to have the pt pain free upon arrival to the ER.

I love hydromorphone for orthopedic trauma pts (thank you medicoca for that valuable lesson...I would still be pushing morphine if it wasn't for him). I can't tell you how impressed I am with this drug's ability to control pain in orthopedic trauma pts. Not only do you feel like you've helped someone, around where I am a medic you get the shock value of the ER staff screaching "DILAUDID!!!--don't you need a Dr's order for that!!!" Hell, even some of the ER docs think we shouldn't have it -- all the more reason in my book to use it. Alas, now that we are using it more the shock value is wearing off...oh well, atleast the pt gets relief. The other thing I try to do is give some more of whatever pain med just as we pull into the ambulance bay, holds the pt over while the ER can get them situated and maybe even let's them tolerate the xrays if the RN doesn't manage to get them a pain med before they go for films.

Valium is my drug of choice for back pain/spasams. Morphine for "chest pain" and burns and anything else you can think of that my be even slightly painful.

Burns are nasty...haven't had to treat one yet as a medic, but saw a few when I worked in the ER. Just think about getting a steam burn when you cook mac-n-cheese...think about how bad that sucker hurts for almost 24hrs...now imagine having that type of burn on 8% of your body!! And that sick sadist of a medic didn't "want to be doin' pain control"?!?

[CamanoMedic]

I had a Pt 18 YOF about a two weeks ago with partial thickness burns to her left arm approx. 8% involving her upper arm , forearm,wrist and the back of her hand. Her HR was about 130 RR 28 shes in moderate distress from the pain. I was working BLS at the time and one of the paramedics says to me " we dont be treatin pain management" I replied with "REALLY" at which point the medics partner says he will ride with the patient. He gave her 2 mg of morphine and like magic her HR went down to 80 and she stopped cursing. After bringing her to her hospital of choice which was about 25 min. away i was returning to my truck and again the other medic was like "just to let you know we dont treat that". I just got in my truck and drove back to post. I must also add that the call went out 20 min before shift change. I just want to know other peoples input on this

I think these guys were being a little lazy. I will generally always medicate for pain. Especially for burns which can be very painful.

[anthonyt]

You're not serious are you?


um, yeah... thought it was a good point.

[jdemaio]

um, yeah... thought it was a good point.
hey, thanks

[medic pathetic]

The word from the supervisors here is "drug 'em till they drool." Just don't let the medical director hear you are saying it. Which is strange because it's one of those things that came up in their meetings.

they are very aggressive here as well.

[Dorkfish]

We don't have a teired system here . FD gets on scene and does their thing , then we put them in the truck and haul . All first line trucks are ALS . Pain meds are used if the medic sees fit . I agree , get the pt to the ED ASAFP . Comfort measures are good , and I would want them if I was hurt or burnt badly , but definitive care is the most important thing . We just got morphine on the trucks a couple of years ago . Some Med Control docs will not let us use it . One stated she doesn't like to give it because it makes people throw up . Now I don't like to clean up puke in my ambulance , but if I am hurting that bad , juice me till I puke . I'd rather puke ( which is not my all time favorite thing to do ) than hurt .

[1medicprincess]

We don't have a teired system here . FD gets on scene and does their thing , then we put them in the truck and haul . All first line trucks are ALS . Pain meds are used if the medic sees fit . I agree , get the pt to the ED ASAFP . Comfort measures are good , and I would want them if I was hurt or burnt badly , but definitive care is the most important thing . We just got morphine on the trucks a couple of years ago . Some Med Control docs will not let us use it . One stated she doesn't like to give it because it makes people throw up . Now I don't like to clean up puke in my ambulance , but if I am hurting that bad , juice me till I puke . I'd rather puke ( which is not my all time favorite thing to do ) than hurt .

You know the only time I have seen a patient throw up is when the morephine is pushed too fast. In our protocol is states that you push 1mg of morephine per minute. (The reason for this is two fold. 1. You don't want to knock out there resp drive. 2. To prevent them from throwing up).

[jdemaio]

One stated she doesn't like to give it because it makes people throw up .
Maybe he has never seen morphine given properly. I have never seen a patient vomit from morphine...the ride in is a different story, but from the morphine, never.

[prncssmdc]

Maybe he has never seen morphine given properly. I have never seen a patient vomit from morphine...the ride in is a different story, but from the morphine, never.

Heard of it, never actually saw it happen. I do know they pounded this into our heads in school, not to give morphine too fast or they'll puke...but nope, never actually witnessed it. (Damnit, now guess what's going to happen when I start my rotation again...I'm just going to shut-up now.)

As for shutting down their respiratory drive, you would have to give a tremendous amount to do that, I would be more worried about giving smaller dose after small dose creating a cumulative effect and that causing respiratory issues, hence the reason why I spell it out for the RN's if I do something like that - make sure they listen. Last thing I need is grandma with the broken hip being tucked in some hole of a room in the ER, unmonitored going apenic after I drop them off because the morphine finally caught up to her.

[medicgoddess]

Never had anyone puke from morphine but it is a priceless thing when I have a stupid ass person who overdoses on pain meds and I can push Narcan a bit fast. I don't mind cleaning up the truck if I can make an idiot sick. LOL :puke:

[jdemaio]

Last thing I need is grandma with the broken hip being tucked in some hole of a room in the ER, unmonitored going apenic after I drop them off because the morphine finally caught up to her.
Hey, after you drop the Pt off and give report, it's the nurse/tech/doc's fault if they don't monitor their Pts, not yours. Just give a thorough report, the rest falls on them.


I don't mind cleaning up the truck if I can make an idiot sick.
Good, maybe you can come clean my bus if you don't mind cleaning up puke.

[anthonyt]

I too have ONLY seen MSO4 cause puking when its shotgunned... given slowly (I usually give it in 2 mg increments, up to the desired effect) all of my patients have tolerated it well save for an allergin reaction or two.

But a word of caution on shotgunning the narcan... Actually saw a nurse shotgun it and caused a cardiac arrest as a result of a very severe and acute withdrawl from the narcotics... Didn't believe it, myself... talked to a few docs and they all told me that its a very rare thing... but, it does happen in patients who are severely dependant on narcotics. It usually takes, they said, more than 2 mg given quickly, more like 4-6 mg to cause something like that, but cautioned that it is possible with 2mg, if given fast enough.

So.... just be careful, else you may be staring at a medical review board trying to justify why you felt the need to make someone sick. Even given slowly, narcan will illicit abd cramping, and a case of the runs. It may take a little longer to happen, but trust me, it will... and the longer it takes to come on the more sure you can be that your patient is lucid enough to completely appreciate it. Especially since, in my experience, there is never enough time to make it to a bathroom, once it starts. And, it gives you time to kick em out of the bus to sit on the curb and talk to the cops when it happens, thus negating the need to clean the truck...

Not that I want to condone the use of illegal narcotics, (Ask Mike, he's been there to witness my course of treatment for such patients) but consider that no matter how miserable you make them, you will never cause them to see the proverbial light of day, they will continue to use and occasionally OD until they do it somewhere that they wont be found for a long time.

[1medicprincess]

No two teired system here. Just our ALS service and fire dept (of which most are ALS). So pain management enroute should happen. However, if we were teired and one of our BLS trucks delayed transport instead of going enroute and meeting a medic on the way-heads would roll I'm sure.

Working in two different systems. One teired system and the other not. I would have to agree when it comes to diffenative care rapid transport is all ways key and if it is als go with pushing drug for pain relief when warrented you got it get orders and push it. If bls is all you have rapid trans with O2 and if you can meet up with an als unit do that waiting is not an option because you are looking at possible shock and diffent infection just a few thoughts.

[mediccjh]

Whenever I give morphine, not only do I give it slow, but I give a 12.5 mg Phenergan chaser to prevent status barficus in the back of my bus. Works every time.

[1medicprincess]

Whenever I give morphine, not only do I give it slow, but I give a 12.5 mg Phenergan chaser to prevent status barficus in the back of my bus. Works every time.

Wish we had phenergan in our boxes.

[bubbamedic]

Wish we had phenergan in our boxes.

Had it and now we are limited on it. We were "snowing" too many people for the hospitals. They can not kick them out until they are certain the AMS is from the drug, not the condition, soooo there are a lot of beds occupied for some time.

We are to use Anzemet for pukers with AMS ie drunks.

We use Morphine and Fentanyl here. Shotgunning just about any meds can cause adverse reactions or damages. We have twisting roads though out our conuty (Mountains) and we see a lot of pukers. Hard to tell if it is the driving or the conditions.

Pain management is aggressively pursued here. Go thing too.