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.