The Church Lady and the Ambulance Attendant

The woman heard a pop as (twisting) she tried to help her (stumbling) mother out of her wheelchair and into the church pew. The pop came from the woman’s knee and she crumpled in pain. She screamed again as we tried to pivot her on her good leg onto our stretcher. The entire congregation turned at that sound. I felt like a barbarian in the gates. There had to have been a gentler way to move her, I just didn’t anticipate the little bit of movement would cause such pain — such a loud scream. My partner and I try to talk soothingly and get her all cushioned and comfortable, trying to cover up the memory of that scream, and maybe get her to see us a little less like untrained ambulance attendants (on a work-release program) and a little more like trusted caregivers.

Out in the ambulance, we elevate her leg, and wrap ice around the knee. From the pop, I’m guessing she tore a ligament. I ask the woman how much pain she is in.

“A lot,” she says. “Ten of ten. It hurts.”

After she tells me she doesn’t have any allergies, I say, “I can give you morphine.”

She looks at me with an evil eye. I’ve already caused this church woman pain by my bumbled patient-handling methods, and now I am trying to push morphine on her.

“I’ll bear it,” she says. “You don’t have any Tylenol, do you?”

I shake my head. I start to tell her morphine is really not so bad, but she isn’t looking at me. She looks at her iced and elevated knee like she is pissed that life has put her in this situation, forced to ride in the back of the ambulance with a painful throbbing knee that she must bear because she certainly does not trust the man fate has put in the back with her.

I wonder how it would have come out if I had just told her I was going to give her a little something for her pain, and just gone ahead and given her the drug. Naming it probably wasn’t the smartest thing. She’s a church lady and morphine might as well be the devil to her.

If they are awake and alert, what obligation do we have to our patients to explain how we are treating them? How much detail do we have to use? Do we have to tell them we are giving them medication? Do we have to name the drug?*

If I had just said, “I’m going to give you something for your pain,” and hearing no protest, gone ahead and given it to her, she’d be feeling better right now. But maybe if we had been smoother and truly careful with our move, we would have spared her pain, given her no cause for a scream, and she would have taken our morphine on blind faith in her Good Samaritans.

I don’t know. As it is, I’m feeling quite guilty. I watch her grimace as we bump down the highway, patient and ambulance attendant.

***

* I think the answer is probably yes to all of those questions. In practice, I tailor my explanation to the patient on a case-by-case basis depending on my guess of the patient’s understanding or desire for an explanation. To one patient, I might go in detail about the pharmacokinetics of Cardizem as I prepare to treat them for their rapid afib, to someone else, I might just say, “This will make you feel better.” I do know that the word “morphine” has negative connotations to many people. I wish it had a nondescript trade name or better yet a market-researched product name. I’m going to give you Tincture of Unicorn. 5 milligrams of Happiness. A touch of No Worries and you’ll be all set.

12 Comments

  • Edward says:

    Tincture of Unicorn!I love it! Elixir of Mr. Sandman kills the pain every time.

  • Anonymous says:

    Honestly (no pun intended) I think you should just keep telling the truth. Let sober/competent adult patients make their own choices. If they don’t want it they don’t want it. And, for the love of god, when are you getting fentanyl? If they’ve never heard of it, they will be more likely to accept it. And it works WAY faster than MS, usually without all the nausea and such.Just my 2 cents. Keep up the good work.

  • PC says:

    Thanks for the comments,I like the Mr. Sandman line.You have a point with the fentanyl. We are discussing it at our regional medical meeting next Tuesday.Thanks again,PC

  • PDXEMT says:

    Fentanyl is the way to go. Not only because people don’t know what it means — though usually I just say “pain medication,” and tell them the type if they ask — but also because it is less vasoactive and works faster. Also it wears off faster. On the one hand, I believe in telling patients the truth and letting them make their own decisions. On the other hand … I hate to see people hurting. It’s a delicate balance, with no right or wrong answers … as are so many things in this business.

  • AlisonH says:

    As a mom with a child away at university who’s allergic to morphine, if you were to give it to her without telling her what it is! Please don’t. I’d go with telling Church Lady and the like that there is a time and a place for this med, and this is one of them. Should she so choose. Empowering her in her extremity can make both of you feel better.And if she is prepared to just live with the pain, you need to be too, hard though it is to see it happen. Which comes from your compassion: good for you on that.

  • Rogue Medic says:

    If the patient is allergic and, even though you asked about allergies, did not mention it as an allergy, it allows for one more way to avoid this problem. If they are unreasonably afraid of morphine and think it is “the most foul, cruel, and bad-tempered rodent you ever set eyes on!” that is her decision. You can present her with facts, but it is her pain, even if you feel partially responsible for the amount of pain she is in.Playing a little of Mr. Sandman’s music might not be her idea of a good time, either.As far as fentanyl is concerned, this should provide you with some information to help with your regional medical meeting. Public Perception of Pain Management. I can email you the entire “Prehospital Emergency Care” article and a bunch of other studies on fentanyl use by EMS. Fentanyl is much safer than morphine, some people just have a hard time recognizing this.roguemedicblog@gmail.com

  • Medix311 says:

    Some great thoughts about medication administration. More often than not, I tell the patient the name of the drug I’m going to give them. Often, they don’t say they have a morphine or phenergan allergy, but when I tell them what I want to give them, they say “no, I have bad a reaction to that.” So then I go to the back up. I’m lucky enough to carry zofran as a back up, and dilaudid and demerol.I believe that not telling the patient violates one of their basic rights. They are in charge of their medical care and can accept or decline any treatment you offer them.But you’re also right that we (as a profession) often gloss over the details when obtaining that “informed consent” we all remember from medic school. How often have you told your patient that in addition to reducing their pain, the morphine you’re about to give them may make them nauseous and cause them to vomit, that it could drop their blood pressure, cause them to lose consciousness, or even slow their breathing?

  • Rogue Medic says:

    I am very much against telling patients about nausea or vomiting. It is very rare that my patients have nausea or vomiting, even with large doses of morphine. The suggestibility of patients is the reason for withholding this information. How many drugs do not have nausea and vomiting as listed side effects? How many patients develop the symptoms you describe to them?I used to work with a guy who would tell patients that NTG would cause a headache, that was how they could tell it was working. I had to threaten to cause this moron a headache, because my patients do not need a headache, no matter how suggestible they are. If they develop a headache, that can be dealt with later.While the patient’s experience of nausea and vomiting may be very uncomfortable, my experience is that the morphine acts to relieve nausea caused by pain far more often than it causes nausea or vomiting. The suggestion by some “experts” that an antiemetic should always accompany morphine administration is an old doctors’ tale, it has been disproved by research, and should be ignored or ridiculed.Nitroglycerin can also cause a drop in blood pressure and a loss of consciousness. I have never seen a loss of consciousness, even with large doses of morphine, but I have seen it with NTG. Do you advise patients of these side effects of NTG when giving NTG?I tell patients what I am going to give them and a little about the drug. If the patient asks, I provide further information about side effects, but my experience with the medication is weighed most heavily in that presentation. Most side effects seem to be due to the rate of administration. If you give medication in a way that is slow, the side effects are minimized. After rate, the next most common cause of side effects seems to be the dose. I have found that 20 mg or 30 mg of morphine panics some people, while others are able to use their training and actually assess the patient. After assessing the patient, they may give more morphine, or another opioid, to deal with the patient’s pain.How much informed consent is appropriate in the emergency setting? Whole different topic.

  • PC says:

    Great comments all.Thanks for the contribution.PC

  • Anonymous says:

    As a an unfortunately frequent patient in hospitals and the like, I truly hope you always tell your patients what you are giving. I might, for instance, become so panicked about your latex gloves triggering another episode of anaphylaxis that I might forget to tell you about my allergy to dilaudid especially if I was also in pain.

  • Anonymous says:

    When I fell and broke my hip, I wouldn’t let the EMTs touch that leg and I don’t know why. I wasn’t in pain, so maybe I was a little shocky. In any case the next thing I knew I was outside the house on a stretcher headed for the ambulance and then went out again. No one asked if I wanted “a little something” but I realized later I’d been given morphine. Which is fine with me. I recall someone asking if I was allergic to anything which I’m not. Frankly, the EMTs did what was obviously best for me at that moment and I was and am grateful.

  • cathairinmyknitting says:

    I would much rather know what it was, if it were me in the ambulance. As other commenters have said, there's always an allergy problem. Yes, you asked her about allergies, but since people confuse intolerance with allergy ALL the time, it can happen in the reverse sense as well. Love your blog, by the way, thanks much for sharing!

Leave a Reply

Your email address will not be published. Required fields are marked *