Should you withhold Pain Meds if close to hospital?

[Kiwiology]

Good on you mate, I think analgesia is probably the most important part of prehospital care.

[scubanurse]

Good on you mate, I think analgesia is probably the most important part of prehospital care.

I would think keeping people alive and not killing them would be slightly more important...but yes, pain management is high up there.

Having been a patient and a provider, I am more liberal with pain management. I rode with someone who would never give any sort of pain medication even when indicated in the protocol and it would piss me off because we have a tool and we can do something for them. So often we are in a situation where this is nothing we can do, so why are we not doing something we have and can do for the patient?? Good for you for pushing the drugs.

As far as the nurse who complained...they're probably just wishing that they could have standing orders like yours! It is just cruel to watch someone in pain and not do something for them when we have the capability to.

[spenac]

Having been a patient in the ambulance before I have always been happy they doped me up to help with the pain. Once at the hospital I had to demand a different doctor to get pain management.

Yes I know I did right by dulling the pain. My service has a good reputation of taking time to medicate when possible before even moving patients. At my old service we pushed meds freely for that long bumpy ride, but even here I don't feel it's right to let them suffer, especially considering all the movement during doctors exams and x-rays that awaits them.

As to knowing I pushed the most last month it was because I had to check the narcotics log books when I filled in as shift supervisor. I also try and keep the vial and tape it to my narcotic usage forms when I get replacements. I always have someone witness any wasting.

And I am still in a rural service just in a town with a hospital so even though I pushed the most for the month I bet most of you big city medics push more in a week, if not a day than my entire services 4 ambulances does for the month.

[scubanurse]

I called for a medic once as a Basic because we had a 60 YOF with a nasty nasty fracture/dislocation of her ankle and we literally could not even feel for a pulse without her screaming. When the medic got there they didn't even come in with any bags and pulled me outside the house and said to clear them because it was a simple BLS call. I stood my ground and said I will not until you go try to asses that patient and tell me that she is not a candidate for pain management protocol. As soon as the medic really looked at her, he started a line and gave morphine so we could splint and get her down the stars to the unit.

I was so pissed that he wanted to leave without even seeing the patient and didn't want to give any drugs until he realized we weren't going to be able to splint it without causing her immense pain.

GRR still pisses me off when I think about that call.

[ERDoc]

This nurse obviously has no idea what she is talking about. The literature shows that giving pain medication does not interfere with the exam, in fact it has been shown to improve the accuracy of the exam. Even if you are in the hospital bay, give pain meds. In the time it takes for the pt to get into the hospital, onto the hospital strecher, triaged, wallet biopsied, etc, more meds will have had time to work. I'd recommend keeping a file of studies on the ambulance to show to hospital staff that have no idea what they are talking about. Here are a few to get you started.

http://www.ncbi.nlm.nih.gov/pubmed/17636812?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=3&log$=relatedreviews&logdbfrom=pubmed

http://www.ncbi.nlm.nih.gov/pubmed/17032990?ordinalpos=11&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1070812

That should be enough to get you started. Spenac, I'd make it a point to make sure this nurse got copies of these (as well as the doctor if he/she did in fact complain).

[chbare]

This nurse obviously has no idea what she is talking about. The literature shows that giving pain medication does not interfere with the exam, in fact it has been shown to improve the accuracy of the exam. Even if you are in the hospital bay, give pain meds. In the time it takes for the pt to get into the hospital, onto the hospital strecher, triaged, wallet biopsied, etc, more meds will have had time to work. I'd recommend keeping a file of studies on the ambulance to show to hospital staff that have no idea what they are talking about. Here are a few to get you started.

http://www.ncbi.nlm.nih.gov/pubmed/17636812?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=3&log$=relatedreviews&logdbfrom=pubmed

http://www.ncbi.nlm.nih.gov/pubmed/17032990?ordinalpos=11&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1070812

That should be enough to get you started. Spenac, I'd make it a point to make sure this nurse got copies of these (as well as the doctor if he/she did in fact complain).

Thanks, this pain med issue is not a new one and a concepts that continues to plague the pages of EMS sites. It is sad and to see some of my colleagues who work in progressive areas cannot take the time to learn about progressive changes of the health care system. In fact, this pain medication myth is not a new concept, yet people continue to adhere to concepts that are decades old and quite outdated.

Take care,

chabre.

[HERBIE1]

We were all taught that anyone with abdominal pain should not get analgesics, but I have seen a few exceptions. I've had a couple instances when it was clear someone had a kidney stone- classic symptoms, PMH of same, and we were authorized to give something for pain. Rare, but it has happened.

As for other instances, we usually administer the medication per standing orders and then notify the hospital- never had a problem. Again, after moving the patient and a probably bumpy transport, pain relief is the decent thing to do. Ortho injuries are no fun.

What doc said is spot on. A significant period of time can elapse from when you deliver the patient at the ER to when they finally get a bed, are registered, triaged by the nurse, had vitals taken, and been seen by maybe a med student, a resident, and then the attending. There is no reason why we can't take the edge off until the patient can get "the good stuff" in the ER. I've even administered a second dose (per orders) just before we unload the patient, in the ER bay for this very reason. If we have the means to provide this help, then why wouldn't we do it?

Last week we had a 10 year old boy with 40% burns, 2nd degree, due to spilled oil. No respiratory involvement, thank gawd. I was on the radio getting the proper morphine dose from our pediatric center even before we had the IV established. This poor kid was tough but clearly hurting, and scared to death. Dad- and the patient- appreciated the relief we provided.(BTW- the transport time was only about 7-8 minutes.)

Edited October 12, 2009 by HERBIE1

[EMS49393]

I gave fentanyl last night and I was 8 minutes from the ER. Although the doc ignored me for a good five minutes while I was attempting to provide them with a story, she did come up to me later and in her round about way give me some kudos for providing pain management.

I will confess, and I could care less who blasts me, that I have delayed transport before to give pain meds. I refuse to listen to someone scream in agony with an isolated extremity injury because I don't want to take five minutes to control their pain before I manipulate them. It's simply inhumane to allow a patient to suffer when we have the ability to make them more comfortable. If it's not life-threatening, it won't kill us to take that extra few minutes to provide comfort. If it is life-threatening, it still won't kill us to provide comfort en route if possible.

By the way, JCAHO apparently has huge pain control criteria for their accredited hospitals. It doesn't pertain to us, but it's an interesting little side note.

You keep advocating for you patients and providing them with comfort. I don't mean to sound unprofessional, but to hell with that nurse, you're doing the right thing by your patients and you know it. Don't worry about giving more pain control than other medics either, I'm the same way. Document, have witnesses, and you'll be fine. These crusty old cowboy-up and take the pain people have got to go.

[HERBIE1]

The only thing I would add is that if you ask for analgesic orders and are denied, make certain you ask for a reason, and verify that denial. Depending on your system, you can also voice your objection later and request that someone review that run. If it's an attending on the radio, there's probably not much you can do, but often times it may be a nurse or a resident who may need reeducation as to proper protocols for analgesics.

[chbare]

We were all taught that anyone with abdominal pain should not get analgesics, but I have seen a few exceptions. I've had a couple instances when it was clear someone had a kidney stone- classic symptoms, PMH of same, and we were authorized to give something for pain. Rare, but it has happened.

That is too bad. You should take the articles posted by ERDoc to your medical direction. It is inhumane to with hold pain medications for abdominal patients and analgesia clearly does not adversely effect the diagnosis of abdominal conditions. Teaching people otherwise is doing so against a large body of evidence that does not support such practice.

Take care,

chbare.