Pre-hospital pain . . .

[JLM]

Let me throw a scenario out there for the more experienced of the group

I am finishing up MS-II in Virginia. I have also been a paramedic in the state since I was 18. I still work part time to bring in some extra cash and keep up my intubation, iv, ekg, etc. skills. My problem is this: management of acute pain is a joke in our system. For example, two weeks ago I watched one of our medics respond to an ice-skate rink for a closed ankle fx. I continued to watch as he immobilized, packaged and transported this poor lady as she screamed and moaned all the way to the hospital. His pain management went something like this: “ hang with me sweetheart. We are almost to the hospital and they can give you something for your pain once we get there.” He was well-aware that he 20 mg of morphine in a tubex in his drug box. When I asked him why he didn’t give it, he responded “ I don’t give narcs. You have to put up with too much crap at the hospital if you give them.”

The sad part is he is right. I brought in one of our supervisors from work that collapsed with a kidney stone. Since he was unable to speak, diaphoretic and in the fetal position with a blood pressure around 190/100 I thought that some pain management might be in order. I gave him 5 mg iv morphine q 10 min to try and reduce his pain, but with little success. By the time we got to the ER he had a total of 20 mg morphine over about 45 min. He was able to talk, but his pressure was still sky high and he was still in the fetal position.

And, as usual, when I told the nurses taking report how much morphine I gave, you would have thought the world had come to an end. Granted, they don’t know my background. But—this is what they do to all of the providers. So, while im trying to get my patient (who is also a friend) some relief, the RNs are too busy b*tching at me about giving pain meds. Of course, when the doctor got into the room I told him how much I gave. His response was “well, obviously that didn’t do the trick and his pressure is great. Lets try some dilaudid.”

Luckily the doctor knew me. But, this intimidation of paramedics by the RNs in the ER is keeping them from adequately managing pain in the field. So, I turn to you, the experts. Here is what I want to know:

We carry 20 mg morphine and 4 of narcan in each box along with the typical anaphylaxis drugs (but no anti-emetic which SUCKS!!). And while they are not physicians, paramedics are the only means of extending emergency care out into the streets. While I have heard the arguments from the RNs in the emergency dept, I am much more interested to see the point of view from the docs who deal with these drugs constantly. Is pre-hospital administration of opioids safe?? Do I go to the administration and tell them to get the RN’s off our back and stop intimidating the paramedics – or can the patient wait that 45 min until they get to the ER?? Do I try and re-train my colleagues that narcs are not something to fear?? They are also talking about switching to a premixed nitrous/02 mix for pain in the field. Would that be safer and more efficacious??

Just curious and thanks to all in advance.

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[Mman]

What are the medicolegal issues regarding nonphysicians providing/prescribing controlled substances in the field in your state? While the scenario you describe sounds completely rational and logical, I'm sure there are some big gray areas where people could get into trouble.

 

[psychbender]

First: not a doctor, I'm a fellow medic and MS2 from your state. Pain is one of the most common complaints in EMS, yet we do an absolutely terrible job of managing it prehospitally (nationally, not just here). Three agents exist which can add a good degree of analgesia with an excellent prehospital safety profile: mixed gas nitrous oxide/oxygen, morphine, and fentanyl. Most EMS agencies in this state only carry morphine (are you practicing in the TJEMS or Penninsulas regions?), but with it, we can still safely provide adequate analgesia, provided we take a good history to rule out allergy or any contraindications. The fact that we also carry the reversal agent also makes opioid administration a rather attractive option. Additionally, you should try to get phenergan in your drug boxes to deal with any nausea/vomiting that may ensue (talk to your regional OMD about that).

The nurses should not give you a hard time for doing your job, and just remind them of the fact that your protocol tells you that you can, and should administer said analgesic in the case of pain. I'm really surprised, though, that you got that attitude from an ED nurse. Don't talk to their supervisors, but bring it up to your OMD if he works in the same ED. Have him talk to your fellow ALS providers, and remind them that those protocols are in place for a reason, and its his license they all operate under. Also, you might want to have a training meeting at your agency discussing prehospital pain management, and how this is one of the few areas in EMS where we can actually do something for the patient.

With regards to mixed gas NO/oxygen, several regions or agencies are incorporating this--I know Madison and/or Orange use it now, as well as Fairfax. It can be given quite safely by even EMT-Basics with a little extra education, as it is largely a patient-administered analgesic with few adverse effects when given prehospitally. Most EMS literature shows that it's a fantastic method of pain control, so hopefully we'll see more agencies adopt it in the years to come.

Also, depending on the cause of the pain, other drugs such as diazepam or midazolam also function rather well (obviously, you'll have to discuss this with your OMD, as its not protocol). I sometimes look at protocols in other states and regions for treatment ideas to talk to my Medical Director about, and found several that use benzos for muskuloskeletal pain, and have friends in my locality that have tried it for patients with extremity fxs who were allergic to morphine.

I'll try to find a link to a JEMS article by Brian Bledsoe on the issue of prehospital analgesia...ahh, here it is: http://www.jems.com/news/15308/

 

[zippy2u]

Call your city newspaper, big wig lawyers and mayor and tell them ya got a crisis on your hands. EMS pts.(stress that they are minorities and are poor) are laying in agony while being transported to the hospitals. Interview a couple of these pts. after they have gotten out of the hospital and get some good sound bites like "Every bump in the road was like a hot poker stuck in my eye" and they are having ongoing psychological issues like panic attacks and nightmares. Tell them ya need a doc on every EMS vehicle for every shift. Pay should be about $100/hr. Hell, I'll run around with ya for that amount and we can give MSO4 all day long; you drive. Watch the political goons go into seizures; "where are we goin' to come up with that kind of money?" Yet they'll gladly come up with the money to widen some roads a couple of feet that will take several years. Telling your ER doc supervisor is useless, he doesn't control the purse strings. Reminds me of an old saying: "Life's a biitch, be its pimp." Regards, ----Zippy

 

[johankriek]

the risk of somebody dying from pain is vey small..

the risk of a medic titrating too much morphine higher..

the risk of medics getting hooked on the stuff ifshigher...

the chance that the hospital will have morphine.. 100 percent .. and their pain will be resolved after a physician evaluates the patient..

plus you dont wanna gorked out patient on morphine while trying to get the story from them...

..

 

[Planktonmd]

Morphine is used in the battle field by medics all the time, so I don't see why not on the streets.
In other countries there are actually physicians that ride with EMS, and that takes care of the problem. in the U.S., we don't have that luxury because we are not as rich as these other countries so we have to improvise!
So let's see, the questions are:
1- Can a paramedic safely administer Morphine to patients?
Answer: yes, but your desired level of analgesia should not exceed a minimal dosage for facilitating transport, because you don't want to change the clinical picture before a physician gets to examine the patient. And 20 mg of morphine is more than enough for that.
2- Is it a good idea to give pre hospital emergencies N2O in oxygen by paramedics?
Answer: NO. This is a crazy idea. N2O causes hypoxia, Expands a pneumothorax, expands a pneumocephalus and causes vomiting, none of these things is pretty in a trauma patient.
3- How about using other things like Midazolam or Valium?
It could be OK but again don't forget that your first priority is getting to the hospital as safe and as fast as possible, and to do that you need to concentrate on the basic ABC's.
The golden rule of medicine is: The more things you do, the more likely you will kill someone, so keep it simple.
By the way, the golden rule of medicine applies to everyone who takes care of patients, so it's not only for paramedics.

 

[zippy2u]

JLM, on a side note , you got caught up in one of the classical turf battles that goes on every day in hospitals throughout the country: RNs mishandling paramedics, Resp. therapists that freak if RNs give albuterol txs to pts., CRNAs dissin' AAs, Anesthesia docs who get paranoid about CRNAs going unsupervised. SSDD. It's all good-- just keep on keepin' on... Regards,----Zip

 

[JLM]

I see where everyone is coming from. There are definitely problems with showing up at the hospital with a gorked patient. I work in richmond so our transport times are relatively short. However, there are places throughout central and southwest VA where transport times to the NEAREST hospital are 90 min plus . . .

And that is where the gray area begins. Is it ethical for me to treat a patient for upwards of an hour without an attempt at controlling pain?? Picture, if you will, being locked in a small box with a patient having true acute stone pain for upwards of an hour and a half -- sitting in front of your knees on a cot and begging for mercy. That wrenches your guts . . . not only as a healthcare provider but as a human !! And unless you have been on an ambulance with that type of patient, I guess its tough to explain.

Do the risks of bringing in a 'gorked' patient (remembering that we carry narcan) outweigh the benefits. Again, we are talking about hemodynamic-stable patients.

Is there anything safer we could be using?? All they give us is 20 of morphine and 10 of valium. we do cary narcan but no romazicon. But, i am more than willing to make suggestions to our OMD (medical director).

 

[usnavdoc]

Morphine is used in the battle field by medics all the time, so I don't see why not on the streets.
In other countries there are actually physicians that ride with EMS, and that takes care of the problem. in the U.S., we don't have that luxury because we are not as rich as these other countries so we have to improvise!
So let's see, the questions are:
1- Can a paramedic safely administer Morphine to patients?
Answer: yes, but your desired level of analgesia should not exceed a minimal dosage for facilitating transport, because you don't want to change the clinical picture before a physician gets to examine the patient. And 20 mg of morphine is more than enough for that.
2- Is it a good idea to give pre hospital emergencies N2O in oxygen by paramedics?
Answer: NO. This is a crazy idea. N2O causes hypoxia, Expands a pneumothorax, expands a pneumocephalus and causes vomiting, none of these things is pretty in a trauma patient.
3- How about using other things like Midazolam or Valium?
It could be OK but again don't forget that your first priority is getting to the hospital as safe and as fast as possible, and to do that you need to concentrate on the basic ABC's.
The golden rule of medicine is: The more things you do, the more likely you will kill someone, so keep it simple.
By the way, the golden rule of medicine applies to everyone who takes care of patients, so it's not only for paramedics.

Just for clarification as to what is used by corpsmen and medics "on the battlefield". They have 10mg Autoinjectors for IM injection. The extrication times to definitive care are much greater than here in America and the risk of overdose is much smaller with an IM injection. When I was there every unit had there own protocols as to how much how frequent to dose but it was physician designed for each unit.

 

[psychbender]

1- Can a paramedic safely administer Morphine to patients?
Answer: yes, but your desired level of analgesia should not exceed a minimal dosage for facilitating transport, because you don't want to change the clinical picture before a physician gets to examine the patient. And 20 mg of morphine is more than enough for that.

Most places I've seen generally have morphine only for isolated extremity fxs, chest pain, and burns. And then, the protocol will usually read something like "If pain associated with isolated musculoskeletal injury, administer morphine 5mg IV/IO over 2 minutes; repeat every 5 minutes until pain is relieved, to the maximum of 20mg or systolic BP falls below 100. Monitor respirations and BP closely." To use morphine for anything else (like kidney stones) or at any other dose requires calling the ED and talking to the doctor. I've pushed morphine for kidney stones just once, and it was to a patient with a known history of stones, no trauma, pain identical to last time he had them, and I spent several minutes conferring with the doctor (who was perfectly comfortable with me giving as much as I wanted) to make sure that this was alright with him--I had always been taught not to give morphine in the setting of abdominal pain. I ended up giving two doses of 4mg, which dropped his pain significantly.

2- Is it a good idea to give pre hospital emergencies N2O in oxygen by paramedics?
Answer: NO. This is a crazy idea. N2O causes hypoxia, Expands a pneumothorax, expands a pneumocephalus and causes vomiting, none of these things is pretty in a trauma patient.

Most places I've seen with this have it for isolated extremity trauma only, and after ruling out pneumothorax, etc. A self-administered 50/50 NO/O2 mixture supposedly works great, though I have not seen for myself (we just carry morphine in my town). I can't really comment more on this, as I've only read about it in journals.

3- How about using other things like Midazolam or Valium?
It could be OK but again don't forget that your first priority is getting to the hospital as safe and as fast as possible, and to do that you need to concentrate on the basic ABC's.
The golden rule of medicine is: The more things you do, the more likely you will kill someone, so keep it simple.
By the way, the golden rule of medicine applies to everyone who takes care of patients, so it's not only for paramedics.

Most of these interventions are performed while moving, so extending scene time is not generally an issue. If you're not doing anything else in the back of the truck other than watching the patient writhe in agony while you write your report and check vitals every few minutes, you probably have the time to call the ED to talk to the doc about possibly giving a benzo to help manage the pain. If after discussing the patient, the doctor thinks that giving 2-5mg valium will help, then do it--just closely monitor vitals and be prepared to deal with any negative outcomes that may arise.

To follow the logic of the golden rule too far, we might as well not do anything as anything we might do could hurt them (the IV may infiltrate, the nitro may bottom their pressure, the valium may depress respirations, etc). With sufficient training and education, however, some procedures become relatively safe, and can be performed with minimal risk to patient safety, and offer acceptable benefit. How much providers are allowed to do varies greatly by region, and is directly proportional to the amount of training they are given (and how well their doctors trust them). In some places in the US, medics can give tPA for an MI (with rigid guidelines in place), with very favorable outcomes. Something like that would never fly in my neck of the woods, though, as the initial and continuing education system is just not up to the task of providing that level of advanced care.

 

[Planktonmd]

To follow the logic of the golden rule too far, we might as well not do anything as anything we might do could hurt them .

You are absolutely correct, the more "things" you do the closer to the grave the patient will get.

 

[sphincter tone]

Failure to adequately manage pain pre hospital is also a frequent source of complaints and law suits.

No one is arguing that tenants that transport is treatment for major trauma patients and that pain management should be a distant consideration behind the ABCs if at all. However, these patients make up a minority of the patients that EMS sees.

Much more common are musculoskeletal injuries sustained in minor MVAs, sports injuries and minor falls. While a broken arm may not sound like a big deal, when it's your seven year old with his humerous sticking out of his upper arm and the mean paramedics have to manipulate the injury in order to get him out of the car, onto a back board and into the ambulance, the case for pre-hospital pain management becomes a bit more compelling. Yes, he will get pain meds at the hospital, but it's going to take 30 minutes bouncing down the practically unpaved road to get there.

I'm lucky enough to work in a service with a medical director who is very progressive in authorizing us to treat pre-hospital pain. My two cents are as follows.

Nitrous works well for isolated musculoskeletal injuries for some patients...especially when used in combination with fentanyl. For some people, it's all they need for adequate pain relief, but usually it serves as something to tide the patient over until we can get them out of the bath tub, start an IV, put them on the monitor and give IV meds. You can't use it for patients with respiratory issues (COPD, burns etc) or suspected trapped gas (pneumothorax, pneumocephalus, pneumo-anything, abdominal pain without clear non obstruction/ perforation source etc).

Fentanyl is great and has a short half life so the ER physicians won't be stuck with a patient with a distorted clinical picture due to masked pain.

I think Valium (and Versed) are only useful in treating pain with a strong muscle spasm component (some back injuries) or due to associated anxiety (like in amputations or eye injuries) but that's just my opinion.

While "no one has ever died of pain", the associated catecholamine release has the potential to do some serious damage in certain scenarios... dissecting aortic aneurysm for instance. The potential to do further harm through pain management is there but through education and QA EMS can safely alleviate pre hospital pain to the benefit of all involved, most importantly the patient. It is not absolutely imperative to manage pain pre-hospital, but as a prominent medical director once said "we are practicing medicine, not transport".

 

[jwk]

What are the medicolegal issues regarding nonphysicians providing/prescribing controlled substances in the field in your state? While the scenario you describe sounds completely rational and logical, I'm sure there are some big gray areas where people could get into trouble.

I don't understand why they didn't just radio in for an order from the ER doc. Paramedics are dependent practitioners, operating under protocol's or by direction/order of a physician. That's pretty standard nationwide, is it not? Screw the RN's in the ED - get an order, give the MS (oops, that's Morphine Sulfate - JCAHO might be watching )

We carried MS, Demerol and Valium on our ambulances 30 years ago - carrying controlled substances in an ambulance and having them administered by a licensed paramedic under physician direction is hardly a new concept.

 

[dhb]

MS for a kidney stone??!!!! you've got to be kidding me!

Has anybody heard of NSAID's!! which are the drug of choice in this setting Aspirine (please tell me you do have aspirine in your drug box) or anything you want and the pain is gone in 5 min.

 

[Geri_Gal]

MS for a kidney stone??!!!! you've got to be kidding me!

Has anybody heard of NSAID's!! which are the drug of choice in this setting Aspirine (please tell me you do have aspirine in your drug box) or anything you want and the pain is gone in 5 min.

This post is a joke, right?

 

[urgewrx]

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[jwk]

MS for a kidney stone??!!!! you've got to be kidding me!

Has anybody heard of NSAID's!! which are the drug of choice in this setting Aspirine (please tell me you do have aspirine in your drug box) or anything you want and the pain is gone in 5 min.

Aspirin for a kidney stone? Puhleeeze! Obviously you've never had one.

 

[dhb]

Aspirin for a kidney stone? Puhleeeze! Obviously you've never had one.

HAHA well go on give him 20mg of MS since it's not working it must be good

I haven't had one but neither an MI but i can treat both try it next time 75mg diclofenac.. experience it for yourself

 

[dhb]

This post is a joke, right?

Hi geri come back when you actually treat patients....

 

[Geri_Gal]

I have had kidney stones. Excruciating pain. With the last one, 30 mg ketorolac IV took the edge off a bit, but 20 min. later I was again in agony...

Now -- NSAIDs in the field in addition to the allotted amount of MS could provide better pain control. IM/IV NSAIDs would be tricky to give, though, especially if the pt had a question of head trauma/may need surgical intervention.