Pain Management- What is your take? Preference? Liberal / Conservative?

[wrmedic82]

I heard a long time ago that we as EMS providers are very poor at pain management as a whole. I also was told that when it comes to poor pain management, a feedback loop can occur causing chronic pain. I do not know how true all of this is so please understand Im not preaching the Gospel of EMS. But I wanted to get some advice from some of the more experienced and more knowledgeable providers. ( Bear with me I'm a baby medic)

I also wanted to ask, when asked for pain medication. Are you quick to treat the pain, or suffice the "drug seeker" and to err with the patient complaining of pain. Do you when in question leave that to the hospital to make the call on pain management?

When it comes to drug seekers, do you suffice at a low dose? or say "No Way Jose!"

And now I will ask the question to allow all to get creative. What in a perfect world would you like to use or see used to manage pain?

This is my take on pain management as of now (always subject to change with new education and advice from experienced medics)

If it is pain that I can alleviate without skewing the Dr's assessment ( i.e. abdominal pain) I have no problem being slightly liberal with pain medication based on what their pain scale is. If it is less than a 4, I may hold off and let the Dr make the call. This of course is provided there are no contraindications to EMS pain management.

When it comes to drug seekers I am kinda torn. I do not want to fight the patient, but at the same time I really do not want to be an enabler. And even so, how can I truely be sure they are not really in pain? Even I got accused even after surgery by one nurse of being a drug seeker ( what was funny was I was asking for hydrocodone for pain despite having a dilaudid PCA) I will definitely be open to hear what others have to say which may help clear the air for me on this. It is my patch always on the line and I do not want to put myself in the line of fire.

In a ideal world, for pain levels < 4 I wish we could give tylenol PO 250-500 mg provided no contraindications, > 4, fentanyl would be my preference because of the less likelihood of dramatic drops in BP. Dilaudid would be a good alternative (although dilaudid gives me a migraine) I have seen some Dr's use lidocaine or a local anesthetic derivative to do a temporary block for pain management, but would need alot more training to use, and may not always be practical. Great maybe in theory. But most of the hospitals are within 15 min so better done in the hospital anyway. Rural EMS I could see this being of some benefit.

[Bieber]

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 also wanted to ask, when asked for pain medication. Are you quick to treat the pain, or suffice the "drug seeker" and to err with the patient complaining of pain. Do you when in question leave that to the hospital to make the call on pain management?

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.

When it comes to drug seekers, do you suffice at a low dose? or say "No Way Jose!"

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.

And now I will ask the question to allow all to get creative. What in a perfect world would you like to use or see used to manage pain?

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).

If it is pain that I can alleviate without skewing the Dr's assessment ( i.e. abdominal pain) I have no problem being slightly liberal with pain medication based on what their pain scale is. If it is less than a 4, I may hold off and let the Dr make the call. This of course is provided there are no contraindications to EMS pain management.

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).

When it comes to drug seekers I am kinda torn. I do not want to fight the patient, but at the same time I really do not want to be an enabler. And even so, how can I truely be sure they are not really in pain? Even I got accused even after surgery by one nurse of being a drug seeker ( what was funny was I was asking for hydrocodone for pain despite having a dilaudid PCA) I will definitely be open to hear what others have to say which may help clear the air for me on this. It is my patch always on the line and I do not want to put myself in the line of fire.

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

[wrmedic82]

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

Beiber,

Thanks for your input on this. I will have to read more about EMS pain management in regards to abdominal pain. It has been beaten into our schools not to give pain meds for abdominal pain because it can skew the Dr's assessment. I will say this. Take for example kidney stones. If the patient has a Hx of kidney stones and says "this is definitely a kidney stone" (quote from my wife who has them all the time bless her heart) I would definitely be more inclined to be aggressive with pain control. But like you said it is very difficult to pin point abdominal pain in the field. As far as your comment on drug seeker vs. person w/o obvious pain. I find it arrogant to "judge" whether or not someone is in pain. So I probably unless they are a known seeker, err on the side of the patient and treat the "pain". Thanks it does help out alot. Good insight.

[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.

[HellsBells]

I too am liberal on the pain meds. Even for pts in moderate pain I find its better to treat with an IV or IM med prior to hand off at the hospital. If the hospital is busy, it may be a while before they actually get assesed by a physician, and receive orders for additional pain meds.

I don't have much fear of being fooled into giving meds to a drug seeker, as Bieber mentioned, that person was a drug addict long be before, and will be long after they received that particular dose from EMS. However, I will withold drugs for a certain sub set of well known and documented drug seekers who call an abmulance habitually shilling for narcotics. My philosophy with that patient sub set is to try and discourage them from regarding 911 as a free depostory for drugs.

[medicgirl05]

I give more pain meds than most people I work with. Pain is one of the few things I can actually fix, so when I can, I try. I don't have a set dose, it varies with the type of injury and other things going on with the patient. I usually start with 2-4mg of Morphine and give more as needed. Our protocols do not allow us to medicate undiagnosed abdominal pain. If I think the patient is seeking and is a patient of our medical director, (they usually are as there is only one dr in the county) then I call the dr and ask for advice. I think it is best as prehospital providers that we err on the side of the patient.

[Arctickat]

I am 100% with Beebs on this. I've seen medical and nursing staff giving judicious amounts of morphine 1-2mg in cases where I'd start at 5 and give another 5 if the pain persists. I've gotten the patient to my ambulance for an interfacility transport several times who are still having pain and I take care of it until they can tolerate it. Then I'll stay on top of it to prevent breakthrough. As long as they're still breathing they'll get pain meds, and I don't care if their pressure is 90/50, they'll still get pain relief...just a little more cautiously.

Edited September 21, 2012 by Arctickat

[island emt]

Bieber: Outstanding post young JEDI knight; +5

Well thought out and well documented.

I've long been a proponent of providing appropriate pain relief to our customers. As Medicgirl said, Pain is one thing we can control and it does not need to be withheld from them.

Could be as simple as an ice pack or two, or require narcotics.

Yes there are seekers out there that have every non specific pain known to mankind.

Do your assessment properly and use your education to make an appropriate decision based on that.

Don't get buffaloed by the regulars that know the buzzwords to get narcotics.

Ask them to describe the pain location, intensity and duration.

Ask what causes it or relieves it? , do they take a prescription medication for it? How much & what dosage?

When was the last time they took it?

Ask to see the scrip bottle and see when it was dispensed. count the pills. is the usage appropriate as prescribed?

If any red flags pop up, then pick up the phone and talk to the doctor at the receiving hospital. Let them make the call on their license.

[HarryM]

Have seen first hand paramedics who are horrible at pain management or have gotten jaded and because they don't think the patient is in as much pain based on previous patients (or some other reasoning), they won't give enough pain relief, or any at all. I'm only an EMT and currently completing my degree so I can become a paramedic and we are taught to have a very low threshold for pain relief, and to follow the pain ladder. So start with the lowest strength drug and move to higher strength drugs until you find one that is effective.

Currently I have the ability to administer: paracetamol (acetaminophen), nitrous oxide, and methoxyflurane. I find the latter two are very good pain relievers and it's as much about selling the drug as actually providing it, so the patient is in a positive frame of mind that the stuff is really strong and is going to work.

Further up the ladder we have fentanyl, morphine and ketamine as well as the option to add low-dose midazolam into the narcotics if required. Again we are currently being taught to use both morphine and fentanyl together with the fentanyl for initial pain relief and morphine as a longer term pain relief during transport. Again I've seen some paramedics give morphine in 1mg doses with obviously little effect, and some really good ones who give 5+mg at time and really get on top of pain early and hold it at bay....I'm aiming to be the latter when I finally graduate.

[aherring1983]

I'm usually pretty liberal with pain meds if they are needed, I've been in extreme pain so I can relate to how it feels and won't hesitate to ease their pain up,, plus I've been working in EMS for around ten years now so I know most of the drug seekers in my work area and they know me.