giving Narcotics like candy

[PRPGfirerescuetech]

So then do you give analgesia to every patient that you have complaining of pain? To look at someone that is pink, warm and dry, in no obvious visible distress, BP 110/60, HR 64 and resps of 16, you can say there is no pain-o-meter? If someone presents with "severe" pain that clinically looks like the presentation above, I doubt their pain is as severe as they make it to be.

You have to be able to form a clinical picture from the global presentation of history, chief complaint and clinical signs and symptoms. Treating pain has to be discretionary, just as is the case with giving ASA, decompressing a chest, intubating, etc. There is no black and white.

DustDevil- someone that presents to be cardiac chest pain gets MONA (regardless of 12 lead presentation) until cleared by troponins.

By what basis are you "discretionary"? You can doubt their pain, but can you prove they arent having said pain??

No, you can't.

My question was purely hypothetical by the way, just to get folks kicking ideas around...

PRPG

[kevkei]

By what basis are you "discretionary"? You can doubt their pain, but can you prove they arent having said pain??

No, you can't.

My question was purely hypothetical by the way, just to get folks kicking ideas around...

PRPG

I agree with this but I never said you can prove they aren't in pain. As for being discretionary, it is your opinion of the differential diagnosis vs. the working diagnosis. I've seen too many students want to go with O2, ASA, NTG and Morph just because someone said "I have chest pain" not clueing in to the fact that it is clearly not cardiac. The same holds true to pain in general. Do those people in pain require narcotic (opioid) analgesia or would there be a better choice such as nitrous oxide, Tylenol or Toridol?

I just don't like the idea or practice that if the patient says "I have 10/10 pain" a person responds with an automatic 2.5 of MS or 100 mcg of Fentanyl.

[PRPGfirerescuetech]

I agree with this but I never said you can prove they aren't in pain. As for being discretionary, it is your opinion of the differential diagnosis vs. the working diagnosis. I've seen too many students want to go with O2, ASA, NTG and Morph just because someone said "I have chest pain" not clueing in to the fact that it is clearly not cardiac. The same holds true to pain in general. Do those people in pain require narcotic (opioid) analgesia or would there be a better choice such as nitrous oxide, Tylenol or Toridol?

I just don't like the idea or practice that if the patient says "I have 10/10 pain" a person responds with an automatic 2.5 of MS or 100 mcg of Fentanyl.

Ok kewl, now were on the same page.

Regarding pain management perspectives...my personal opinion is this, anyone with some sort of experience in this business can get an idea of how bad a patient's pain truely is. They look at a grimace scale, pain rate scale, noted diaphoresis, or even heart rate.

But, any vaguely intelligent frequent flyer can pick up on these signs and know when to display them. Especially the "opoid seeking" individuals who are painfully aware of the system.

Should their be more options for pain mgt? Absolutely. Do you really need to hit granny with 2.5 of MSO4 before moving her with her bad hip, or could Nitrous do the trick? Maybe 600 of motrin for that 4/10 knee pain?

Just me spouting off here, any other opinions on this?

[BurnNurse]

OK on the streets we used the drugs sparingly because it was a PIA to get it from telem... also was a big issue in the system i was working in , under investigation for excessive use by crews and ect... while others were stealing it from the lockers at the station.... as for the use now. I think it should be used with good clinical judgment. as far as a doc not believing in it.. the go work renal or the clinic you don't belong in an ER, talking to professionals who are caring for people outside the hospital. I work in a place where morphine/ fentanyl and pain control meds flow like water. Doses that are very high... yet no one walks out a junkie and no one dies from an over dose. Hmmm, Pain management is just as important as other treatment modalities that we use, and should be used by pre-hospital as well as in hospital providers.

[Asysin2leads]

Pain isn't completely intangible. I would like to think if you are the point you need to give analgesia, the patient will be showing physical signs (moaning, screaming, rapid heartbeat, thrashing) to indicate how much pain they are in. If you have a someone with a midshaft femur fracture, screaming their head off, I think I can assume that's a '10' on the pain scale. I'm a big fan of the new push for better pain management. Suffering never helped anyone.

[Ace844]

That brings up a good point that I'd like to hear some of you address. How has the field use of 12 leads affected your use of narcotics for chest pain? If the EKG is negative for signs of an MI, does that make analgesia contraindicated in your protocols or judgement, or the judgement of your online medical control? Or do you still treat the pain the same way as you would have otherwise without a 12 lead?

"DustDevil",

I recently sat thru an EM lecture taught by the director of the RI Hosp. ER. This lecture was on "Risk stratification of chest pain patients, treatment modialities and litigous risk." Essentially what it boiled down to in regards to this discussion is this. 1.) A 12 lead ECG is 98% specific and 50% sensitive. In short, just because you have a "normal" 12 lead doesn't mean your patient isn't having a myocardial event.....As a matter of fact, you could get the same senseitivity of info by a simple coin toss.... (Remeber: the 12 lead is just a snap shot of a few millisecond in time)B.) This is why one needs at least 3 sets of - enzymes and a period of observation, "to rule out" if you will. c.) Tort law has now made it a pateint's "right" to be pain free. It is your duty to try to alleviate it. D.) The "pain" felt in MI can and will usually absolve when the underlying etiology has been appropriately treated, i.e.: MIO2 has been restored with blood flow, etc... The reason most often MSO4 is given isn't so much for the minimal vaso-dilitory effects as anxiety control, and "perception of pain decrese".

Lastly, your decision to treat or not to treat a CP patient's "pain" should have nothing to do with whether you have chnages on the 12 lead. As a matter of fact there is an overwhelming amount of evidence which shows that pain can completely devoid of an ischemic event...

Hope this helps,

Ace844

[Dustdevil]

Thanks, Ace! That's interesting stuff!

[Richard B the EMT]

As a matter of fact there is an overwhelming amount of evidence which shows that pain can completely devoid of an ischemic event.

Would this be a reference to a so-called "Silent Heart Attack," where the patient has an MI, but does not experience any pain or discomfort while having it?

My dad had one, found out about when the Cardiologist doing an annual routine EKG asked him, "Mr. B, when did you have the heart attack?" and my dad responded, "What heart attack?"

[Ace844]

Hi All,

For those who are interested, here are a few recent journal articles which provide info on my previous post.

The sensitivity of cardiac markers stratified by symptom duration

Prevalence of acute myocardial infarction and other serious diagnoses in patients presenting to an urban emergency department with chest pain

Potential diversion rates associated with prehospital acute myocardial infarction triage strategies

Non-Myocardial Infarction Chest Pain

Psychiatric Issues in a General Cardiology Practice

Hope this helps,

Ace844

[Guest]

We went over this in medic class as well. No chest pain complaint (medical) should continue to have pain while in the care of EMS, 12 lead or not.

Also, most diabetics do not have feel chest pain during an MI. I have seen this first hand on many occations while working in a dialysis center ( good thing they have continuous monitoring while on the dialyzer)

Still good information Ace. thanks for posting it.