Pain Control

My new preceptee is doing great. On most calls I am a complete invisible man, just sitting back and watching her work. If I offer anything, it is usually just a small trick of the trade. Since she is only part-time, we only work together a couple times a week so I am still doing plenty of calls myself on her off days.

We gave morphine the other day to a lady with back pain, which until the new protocols come out in another month, still requires medical control. I told her how to ask for it(ask for an initial amount and then further doses based on response), and she gave such a good radio patch, the med control doctor said, “yeah, go ahead, give her whatever you said and how you said it.” It was an amazingly precise patch that went something like this “I’d like to give her 0.05 mg/kg, which for her is 5 milligrams slow iv push to start over 4-5 minutes, followed in ten minutes, by an additional 2 mg q 5 minutes titrated to pain, provided her pressure, respirations and ventilations remain within normal limits to a total dose max of 0.15 mg/kg if necessary.”

I was as impressed as the doctor was.

Today working by myself I called in for permission to give morphine to a 40 kg 102 year old woman who was fully alert and functional but had back pain that she rated as an 8-10. I asked for 2 mg to start followed by an additional 2 mg if her pain persisted and her vitals remained normal. I only got orders for the initial 2 mg and was told to call back if I still wanted more. I was a little annoyed with this doctor, who usually always approves my requests. The 2 mg hardly touched her, but when I tried to call back (after ten minutes — her pain was 7-8), I couldn’t get through because the radio operators were tied up on 911 calls. She was still in pain when we got to the hospital and when I got the signature from the doctor on my narc sheet, I mentioned the 2 mg hadn’t helped much, and that I had tried to call for the other 2 mg but couldn’t get through. He grunted as he signed. I thanked him without judgement. I hope I didn’t come off as disrespectful. I know he was thinking — 102 years old, 40 kg, I don’t want her to go into respiratory arrest, but I was thinking — she’s 102 years old and she shouldn’t be in pain and I ought to have some judgement allowed here. I’m not going to give her the second dose if she is getting obtunded. Later I talked with another doctor — the one who took care of her and he said she had a compression fracture, but the 2 mg of morphine I had given her chilled her out nicely so he didn’t give her any more.

There is a certain dilemma here with prehospital morphine. You want to give them enough to take away their pain, but not so much that you completely zone them out at the ED. The problem is the transport can be rough on the patient as compared to the stillness of the more comfortable ED beds. The 102 year old was in pain during the transport and only after laying in a quiet comfortable ED bed for awhile did she start to chill out.

Later in the day, we got a call for an 80 year old lady who had dislocated her hip. When I came in the door, the family recognized me and I could see some relief in their eyes that I was there. “Oh, I’m glad it’s you,” the daughter said. That’s about as nice a compliment as you can get. Sometimes I get tired of doing so many old people calls in my town, but one of the benefits is I really get to know the patients and their families because so many of them are repeat customers. This is the fourth time (over a period of years) I have been to this lady’s house because her hip keeps popping out. I have the routine down. After getting her vitals and doing a full survey, I give her 5 mg of MS SQ, which I have found is a much gentler way to start getting the drug. I then get an IV (I usually end up with a 24 in a tiny arm vein because that’s all I can find on her) and after ten minutes or so, I give her another 3 mg SIVP. We then wait another five minutes or so until she is good and relaxed, and then we gently get her on a scoop stretcher and pad her up before we carry her out to the ambulance. My partner drives nice and slow. By the time we get to the ED, her eyes are closed and her pain is down from the initial 10 to maybe a 1 or 2. What’s nice about our protocols for extremity injury (including hip) is for the most part we are given the leeway to give the amount necessary to take care of a patient’s pain. Soon our protocols will be expanded to include back and spine pain, as well as sickle cell crisis on standing order. In addition we will be able to give up to 0.15 mg/kg up to a 15mg max, where now we can only give a max of 10 before calling.

If my preceptee learns one thing from me, I want it to be to treat a patient’s pain. Not just with morphine, but with lots of pillows and allowing time for the drug to work before moving the patient. And to not be afraid to call medical control back and ask for more if the patient needs it. Sometimes they will turn you down (you can’t take it personally), and at least you advocated for your patient.

8 Comments

  • Anonymous says:

    Nicely done; I try to instill the same ideas in my own preceptees. The idea of using “lots of pillows and allowing time for the drug to work before moving the patient” tends to be one of the harder lessons to teach. A common hangup is that these comfort measures (done properly) extend our scene times considerably. The textbooks say that time spent managing an airway at the scene is time well spent, but the same textbooks say nothing about comfort measures.How do we justify lengthy scene times spent waiting for the patient to be “good and relaxed?” My answer is that we paramedics have the authority to decide whether or not the golden hour applies. We get to decide when the patient’s needs are non-critical and we will be trusted to choose between rapid transport and gentle handling. This is the essence of street medicine.It seems that new paramedics often are uncomfortable excerising such a degree of independent judgment at first. By contrast, nurses-turned-paramedics have no qualms about the idea. Does anyone have a better answer?-Just a medic

  • Anonymous says:

    I came from a 911 service that had very liberal policies on analgesic. But now where I work, in a large urban system, we have very restrictive policies, relative to the place I used to work. Just like the research has shown, due to the fact that we must call for orders, regardless if they’re approved or not, we are much less likely to administer medications and much less comfortable with them.I think people have this idea that anything more than 2 mg of morphine is a recipe for a Lethal Injection. There’s the additional paperwork required, the seeming heavy scrutiny of narcotic use, and the fear of the unknown. I wish I could go to the physician board and say, “IV Epi has more of a chance for untoward effects than morphine, and we have IV epi as a standing order!” But I can’t because, as the new guy, it wouldn’t fly. Maybe in a few years.I think we get pretty calloused about drug seekers. But I don’t care. It’s not my morphine. It’s not my bill. Of all the drugs we carry, the amp of morphine is among the cheapest things. There’s also a hassle about getting the drugs out, drawing them up, doing all Your post got me thinking about my own hesitations to call for orders. Part of it is the fact that when I call, I feel like it’s a “Mother, may I?” deal. I don’t feel like I’m trusted so I have this shitty attitude about it. But who is that helping? My ego or the patient? I guess I need a paradigm shift. My medical license is an extension of a physician. All the care I can provide legally is granted from above, so I guess if there is an issue about providing analgesic relief to patients, I need to look at it as an issue that the medical director has, not my own personal issue. It would be a lie if I said part of it wasn’t due to laziness. It’s shameful to admit it, and even posting this anonymous, I’m still a little embarrassed to say that there have been times when I’ve said, “Well hell, we’re not far from the hospital. What’s a few bumps and jolts? Plus I have all that extra paperwork” That’s poor care. It really is. I need to get back on top things and quit looking for excuses NOT to use morphine, and start challenging myself on why I shouldn’t. No matter if it’s extra paperwork or not. What the hell anyway? I get paid by the hour, not by the call.

  • Dave the Ambo says:

    I work in Melbourne, Australia, and from what I can gather, we are given a very large degree of autonomy in deciding on the best care for our patients in comparison to other services. Once we are trained to ALS, we can give up to 20mg IV Morphine as required. This is for any pain, regardless of the type of injury. I remember when this was limited to 10mg, since the increase a couple of years ago, it has made it much easier to control a patient’s pain. Plus if required we can consult for further.Generally our judgement is trusted. If for some reason we are unable to consult due to communications problems or other, then we are usually well supported in working outside our guidelines within in reason. Just as long as it is within the patient’s best interests.In regard to spending time on scene to make sure a patient is comfortable before moving them, I believe this is essential patient care. Our service does support us in this. A time critical patient is a different story.I have struggled in the past about how much pain relief to give, especially if there is a chance the person is a drug seeker. But now think it is much worse NOT giving pain relief to someone who needs it, than being fooled by a seeker. Our Ego usually doesn’t appreciate being duped by the seekers, but does it really matter? It’s not our fault drugs are easy to get through the medical system.I like to see a patient as comfortable as they can be during transport and on arrival at hospital. I think we should do everything possible to achieve this.

  • james says:

    I agree that there is too much of an idea of “rapid transport” of being the paradigm which EMS should always operate under, regardless of the situation. However it is ingrained in our psyche from the moment we take our basic course we’re taught ABCs->Assess->Package->Transport.In this patient with a hip injury, is the few minutes spent waiting for the morphine to take effect going to adversely affect the patient? Is it going to exacerbate the injury or make later care more difficult? Probably no to both those questions.So in this case, analgesia before moving the patient is the medically correct and humane thing to do. And in a business-sense, it is good customer service to make sure your patient is as comfortable as possible.Sometimes I don’t think the telemetry docs realize how much pain a patient is in. Would they want to be in pain themselves if they didn’t have to be? Would they want to watch the patient wincing and moan at every bump in the road? Would they want to be that person wincing and grunting?I come from a very restrictive EMS system where getting narcotic analgesics orders is like pulling teeth. And the usual dosages they give are gross under doses. Not enough morphine to sedate a gerbil. At my service, we had a degloving injury several months ago. Pt got his hand caught in an industrial laminating type press machine. Fingers crushed, skin pealed back, open fractures. A mess. Pt was probably 115 kg. Our local protocols dictate 0.1 mg/kg SIVP for morphine, subject to physician discretion after a required online consult. That should mean about 11 or 12 mg of morphine. Physician ordered 5 mg. No relief at all. Might as well have been pushing saline….

  • PC says:

    Thanks for the comments.I think the bottom line for us, is to advocate as strongly as we can for the patient. Wait on scene if you have too, try to get standing orders expanded, and when you have to call for on-line orders, don’t be afraid to ask for all you need. I am trying to learn this lesson. Instead of just asking for what I think I might get, I’m starting to ask for higher doses with discretion to give more based on pain. Each time I call I have to get the MD signature so I always seek him out and let him know whether the amount he let me give worked or whether it was insufficient. I use to take it as my failing when I was denied, now I try to make it an educational opportunity for me and the doc.

  • Anonymous says:

    Hi, i work in NZ where, like Australia i suspect, we do not need permission to use morphine. In fact there is no limit, and intractable pain can be treated using combined morphine and low dose midazolam, providing the patient is older than 10 and conscious. Obviously midazolam is used with caution in low .5 mg increments. Now i dont want this to turn into a “my procedures better than yours”, debate, especially since even with our liberal procedures with morphine, patients still get undertreated, or not treated at all (particularly paediatrics). The problem isnt our respective procedures (although i do sympathise with U.S. paramedics having to get a doctors approval first), but our attitudes as you all acknowledge. For example, not wanting to administrer MS to a child for fear of resp. depression, thinking a patient should just toughen up, the MS will mask her symptoms, not wanting to give MS for fear of creating an addiction or suspicion of drug seeking are all poor excuses i have heard and seen (and to my shame, used on occasion). Pain management by EMS/paramedics is poorly performed worldwide. Check out the studies. Furthermore, early effective pain management has been shown to improve recovery times.Let whoever is in charge whine about your scene times. In our case its dispatchers waiting for you to clear the hospital, to give you another job. They dont give a sh!t about your patient care, they just want jobs off their screens. I usually give them a call after our 15 minute pager beep to tell them we will be longer (so stop bothering us!). Good on you for being a mentor, sounds like you make a great teacher.

  • PC says:

    Thanks for the comment. I wish our system was more like yours. Its getting there.

  • Anonymous says:

    Only time I ever rode in an ambulance was after a minor motorcycle accident – turns out the main damage was a grade 3 AC separation. I know now that my position (cupping elbow with uninjured hand to support arm) is a classic indicator. Anyway, I got strapped to a board, driven to the ER, and rolled across a COBBLESTONE entrance. No, I wasn’t dying, but what kind of idiot designs an ER entrance with cobblestones?

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