Bieber

Good on you, man. Another thing to consider is the adverse complications that can result from severe abdominal pain. I recently posted a scenario based off of a real life case I had where the patient was hypotensive and bradycardic secondary to vagus nerve stimulation from bearing down so much due to their pain. I think you posed some good questions, and you're putting yourself ahead of the rest of the folks you went to school with by getting on these forums and questioning some of the things you were taught.

When is the essay due by?

First of all, great topic, man! This is a matter that I'm very passionate about, because you're right, we as providers ARE awful at pain management (1, 2). First of all, I'm not especially experienced in EMS (EMT since '07, part time EMT since '10, part time medic since '11 and full time medic for about a year now). But I'll weigh in just because this is an incredibly important topic in EMS, in my humble opinion. I am very quick to treat pain, unless the patient is obviously drug-seeking. If I have a significant amount of doubt, I'll leave it to the hospital, but I always try to err on the side of treating pain. If I'm treating pain, then no, I won't skimp out on the dose. Especially considering if it is a patient with a history of narcotic abuse who's in pain, there's a chance that they've already got a tolerance to low dose pain medications. In a perfect world, I'd love to have ibuprofen/acetaminophen for mild pain, nitrous oxide for mild-moderate pain, and fentanyl for moderate-severe pain (with the option of combining benzos with it in there). Question: how much can you tell from a physical exam of the abdomen? How much more do you think a physician can tell than you based on the exam alone? Probably not much, right? Withholding pain management from patients with abdominal pain is inhumane, and given modern diagnostic capabilities, is an inhumane act that comes without benefit (3). I'd encourage you to look at the literature and reconsider your approach to treating abdominal pain. Likewise, pain management should not be withheld in multisystems trauma, given the safety profiles of the two most commonly used analgesics in EMS, morphine and fentanyl (4, 5). Is it your job to keep drug seekers from getting high, or is it your job to treat pain? Really, man, that's what it comes down to... Yeah, I understand where you're coming from, but people aren't getting addicted to the single dose of fentanyl given by the EMS crew, it's the prescription Lortabs and oxies that are getting folks hooked (6). Ultimately, you need to ask yourself, which can you live with more? Accidentally withholding pain meds from someone who truly needs it (because if you take the stance that you're not giving pain management to people unless they a.) "prove" to you that they're really hurting; and b.) "prove" to you that they're not drug seekers), or accidentally giving pain meds to someone who just wanted to get high? I know which one I can live with. Also, concerning malpractice, it's not malpractice to be scammed by a drug seeker... but withholding treatment when it's indicated... That might be another matter. How will you respond to the patient who claims that they've suffered psychological harm secondary to untreated pain because you withheld it? It's an unlikely scenario, but a lot less so than the drug-seeker who sues you for giving them pain management when they requested it. (I'll leave it at that, since I'm not a lawyer and some of the more experienced guys probably have better advice in this regard). Good discussion, man. 1. http://www.aapsus.org/articles/1.pdf 2. http://www.ncbi.nlm....pubmed/15829390 3. http://www.ncbi.nlm....les/PMC1070812/ 4. http://www.ncbi.nlm....pubmed/22491566 5. http://www.ncbi.nlm....les/PMC2924527/ 6. http://www.time.com/...1964782,00.html

Occasionally we'll get down to having only three or for units available, and every now and then we'll have no available trucks--that never lasts for very long, though. Once they put out on the radio that we're at "status", everyone starts bookin' it to get available ASAP.

Not thrilled about this. We're just not trained for this kind of thing, and who's going to accept responsibility for the liability that comes along with it?

No, but if you ever find your way to Beloit, KS and go to the Mitchell County EMS station there in town, you'll find a star of life painted on the wall in the training room by yours truly. =) Alas, the closest thing I have to being published is all the nonsense my big mouth has let loose across the internet.

I believe that in large EMS systems, as well as in smaller systems that are unable to either acquire sufficient field experience in intubation or clinical experience in an OR, intubation will in the not so distant future be a skill used only by a small subset of paramedics within the system. Is it a skill that may have a benefit to a certain subset of patients, but frankly, if we can't remain proficient in it, it will be taken away from us. And because it seems like more and more services are choosing to aim for greater numbers of paramedics in their systems (as opposed to fewer, more proficient paramedics), I can't imagine that a lot of systems will be able to continue to justify permitting all of their paramedics to perform intubation. You just can't have four paramedics on an engine plus two paramedics on an ambulance, plus a medic supervisor that responds to all critical calls and expect to have enough opportunities for skills practice to divide up between the whole lot of them.

No! Nooooooo! I will not sacrifice the Enterprise EMS. We've made too many compromises already; too many retreats. They invade our space and we fall back. They assimilate entire worlds ambulance services and we fall back. Not again. The line must be drawn here! This far, no further! And I will make them pay for what they've done.

I won't regurgitate my same old feelings about fire-based EMS, but I will say that as we grow ever closer to health care reform and, more importantly for us, ambulance billing schedule reform, I imagine that the battle for possession of ambulance service contracts will grow ever more heated and the competition will be fierce. Do we, as a profession, have the balls to hold onto EMS and keep it ours? Or will we become "Fire and Rescue"?

I heard about this a while back. Freakin' awesome stuff.

I went from EMT-B to EMT-I to AAS Paramedic without ever having actually worked as an EMT or EMT-I. It's a hard transition if you don't have any field experience, because then you're not only learning how to be a good paramedic, but also a good EMT as well. Working as an EMT definitely helps to get you familiar with how field medicine is done, but it's certainly not something you can't overcome--it just means you'll have to work harder than those who already have field experience. Good luck to you man!

That's atrocious, 1 C. Inhumane, senseless, and--in this case--would have contributed to a worsened condition. I feel bad for those patients who are needlessly made to suffer. Anyway... on to the exciting conclusion of this scenario! This was an actual patient I ran a few days ago. I was pretty certain right off the bat that the patient's hypotension and bradycardia were due to vagus nerve stimulation due to bearing down so hard due to the pain. Like you guys, I administered Fentanyl (75 mcg) and fluid (1 liter total) to the patient, and once her pain level came down (ending pain scale: 1-2/10) her heart rate jumped up to the 70's and her blood pressure increased. The patient was later diagnosed with an obstruction of the common bile duct, a complication which can occur following cholecystectomy. Here's a couple of articles on post-cholecystectomy illness: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015378/ http://emedicine.medscape.com/article/192761-overview http://www.ncbi.nlm.nih.gov/pubmed/7386502 Take away points from this scenario: -Consider vagal nerve stimulation in hypotensive patients (especially when they are also bradycardic) complaining of abdominal pain whose presentation does not suggest other causes for their hypotension (signs/symptoms of internal hemorrhage, risk factors for internal hemorrhage, etc). -Consider bile duct disease even in post-cholecystectomy patients, especially if the patient is complaining of RUQ abdominal pain but has no risk factors, history, or assessment findings consistent with liver disease or which can be attributed to another origin for the symptoms. Hope everyone enjoyed this scenario! Thanks for your participation!

Thanks, Kate! Happiness, I'm afraid to say that it's not eclampsia. An obstetrical emergency is definitely a good thing to consider, though, and something I considered as well. Harry, you're on the right track, but you're right, it doesn't explain the hypotension or bradycardia. This has been a great scenario so far, guys! I'm glad to see so much participation. I'm going to wait a few more hours to let some other folks throw out some final diagnoses and then I'll give you guys the answer by about midnight central time.

Why? BP has raised following 500 mL of fluid and 60 mcg of Fentanyl to around 90 systolic. Now a regular sinus rhythm, rate of about 70. 12-lead is non-diagnostic and shows no conduction abnormalities. Done. Patient had her gallbladder taken out about a year ago. About eight pounds. Why eclampsia? No dyspnea, no complications during childbirth. After another 40 mcg of Fentanyl and 250 mL of NS patient's pain is down to a 2/10 and her new vitals are: HR: 70 BP: 110/64 RR: 16 SpO2: 98% on room air. Thoughts on a diagnosis? Or why she was hypotensive and bradycardic? Anything else anybody wants to add? We'll say we're transport complete now at the hospital, patient's blood pressure and pain have been adequately managed with fluids and Fentanyl. Let's focus on our diagnosis. There's two questions we need to answer: What is the cause of the patient's pain? Why was the patient hypotensive and bradycardic? Ideas?

DFIB, why do you want to give epinephrine or atropine? Doc, no chest discomfort or difficulty breathing. No ultrasound, alas.

After about 60 mcg of Fentanyl and 500 ml of NS, patient's heart rate and blood pressure rise. Your new set of vital signs are: HR: 70 BP: 96/60 RR: 16 Patient adamantly denies any intentional or accidental overdose.

Last oral intake was a meal of roasted chicken approximately nine hours ago. Posterior is unremarkable. No bruising, CVA tenderness. Mike, my findings are yours. Pain response is extreme. Do YOU think it's proportionate based on what you're seeing? Doc, good to bring up the question of the bradycardia in addition to the hypotension. Only med is Zoloft. So, no abdominal bruising, rigidity, or distention. Are we thinking this is an internal hemorrhage, or does someone have another idea? J306, patient has no nausea/vomiting and is not jaundiced, and though she is cold, it is not localized to the skin and there is no presence of petechiae or purpura. Do we think she's cold due to vasopcclusion or from generalized hypotension? Still thinking HELLP syndrome? Why or why not? Why is her blood pressure low? Why is her heart rate low?

12-lead shows a regular sinus rhythm rate of 40, normal axis deviation with no st-elevation/depression, t-wave inversion or other conduction abnormalities. Patient's husband runs and grabs the wife's bottle of Zoloft. It appears that the patient has been taking it as prescribed with no unusual amounts missing. As far as the mental state goes husband states he thinks she suffers from post-partum depression but it otherwise normal and no history of suicidal tendencies.

Que pasa...? =D

No jaundice, no trauma. Still suffering depression, husband thinks it's post-partum depression. Patient adamantly denies ingesting any toxins or anything like that. How do we want to manage her blood pressure? How about her pain? What are we thinking? Do we have evidence of an inadequate pump, volume, or vasculature? Why?

No masses, patient will BARELY let you touch her, and she is very tender to palpation with no rebound tenderness. EKG shows a sinus bradycardia with no ectopy. With some probing patient also admits to having had a cholecystectomy about a year ago and also of depression. No food, objects or toxins, no blood in the stool, urine or vomitus. No nausea/vomiting. Poop is normal, last bowel movement was around eight hours ago. No odor to the house. Doc, pain is sharp, stabbing, no radiation, nausea/vomiting, temp is 98.4, no complications with any of her pregnancies (all vaginal deliveries). Patient was sleeping when her pain started. Abdomen is soft, very tender and painful to the epigastrium and right upper quadrant, no rebound tenderness, no bruising or rigidity. Normal S1 S2 heart sounds with no extra sounds, lung sounds are clear and equal bilaterally. CSC, think back to your abdomen anatomy with relation to the location of the appendicitis, as well as the typical presentation of it (no fever or nausea/vomiting). Do you want to request ALS backup? Patient takes "something for depression" and is allergic to Lortab. HEENT: Mucous membranes moist. No perioral cyanosis. Eyes PERRL. Neck: Supple, no JVD, retractions, tracheal deviation. Chest: Equal chest rise, adequate depth of respiration. Abdomen: Painful/tender to epigastrium and RUQ. No bruising, distention, rigidity. Pelvis: Stable. Posterior: Normal on inspection. Extremities: Neurovascular function intact x4, no numbness/tingling. Const: Afebrile, no recent weight loss. CV: Radial pulse weak, regular and slow. S1, S2 present, no extra sounds. Resp: Lung sounds clear and equal bilaterally. Neuro: GCS 15, Alert and Oriented x3, Affect: severe distress. GI/GU: No melena, diarrhea, constipation, nausea/vomiting, or dysuria. Regular and consistent bowel movements. No vaginal bleeding or discharge. Integumentary: Skin pale, dry. MS: Normal. Mike, no history of liver problems, alcoholism. HIV negative per patient. Patient denies history of aortic aneurism, Marfan's syndrome or Ehlers-Danlos syndrome. Harry, how much Fentanyl do you want to give? You get an IV and begin infusing NS. Distance to the nearest appropriate facility is 20 minutes, and as mentioned above patient is afebrile.

Csc, what is leading you to appendicitis? Would you want to provide any sort of treatment or just transport?

Lol, well per Doc, you get the patient out to the ambulance right about the time fire shows up. Vitals are: HR: 46 BP: 74/48 SpO2: 100% BGL: 78 Pain began approximately 5 minutes ago and is localized to the middle and right upper abdomen. History of G5/P5, with the last birth 6 weeks ago. No cardiac history or new meds. No trauma. Only other symptom is complaining of being very cold.

You are working as a paramedic alongside an EMT in a small city approximately 20 minutes away from a larger metropolitan area when you are called to respond to a patient complaining of abdominal pain. The address is right around the block so you go non-emergency traffic and arrive first on scene, though you know BLS fire will be arriving shortly. You are guided into the upper-middle class home by the husband who leads you to a bedroom where you find a forty year old female patient laying completely still in bed alert and oriented x3 though very soft-spoken and appearing to be in a significant amount of pain, based on her facial grimace and unwillingness to move. You also note that the patient is guarding her abdomen with both hands. Go.

Midazolam and Haldol. Haven't used either yet, but I hear Haldol has quite a kick to it!