I have written often in the past about pain management. It has become my passion in EMS. To me, it is the most satisfying part of the job – to ease someone’s suffering. When I started we needed to talk to a physician on the radio to get orders to use our morphine. Today we can give up to 0.15 mg kg on standing orders. In others words a 220 lb person like myself could receive up to 10 mg given over (at least) 4-5 minutes and if the pain is unrelieved, another 5 mg ten minutes later. If more pain medicine is needed, medical control must be contacted for permission.
The reason we had to contact medical control when I started was a state law that required “simultaneous communication” with a physician in order to dispense controlled substances. That was interpreted to mean on-line control. After I discovered other states did not have a similar provision and that controlled substances were allowed to be given on standing order in those states, I went about changing our state’s law. I met with the DEA (who are charged with overseeing federal and state controlled substances laws), and with the state medical advisory committee. I eventually testified before the legislature on the issue and they changed the law to allow standing orders. Then once that was allowed, within our region, we started at 5 mg of morphine on standing order and then in time upped it to 10 mg and then to the 15 mg we currently have as well as broadening the indications for pain management to include abdominal pain.
I must admit while I have been very aggressive about pain management, over the years when I hit my standing order limit, I tend to stop there even if the patient is still in pain. Why? I guess 15 milligrams seems like a lot of morphine considering when I started just giving two was a major event. And of course, there is that whole I have to call in and bother the doctor (or maybe have my request turned down) barrier.
Once we removed the initial need to call for orders to give controlled substances, the use of morphine went up drastically. But here I recognize that the same need to call the doctor (to go beyond the amount we are now allowed on standing orders) has been holding me up from taking care of my patient’s pain.
So I have decided, be damned, if the patient is still awake, breathing and in pain, just because I have hit my standing order limit, doesn’t mean I shouldn’t call in for more. All I have to do is pick up the radio and ask to talk to a doc. How hard is that?
Now I am saying to my patient (provided they are still reporting significant pain):
“I’ve given you all the pain medicine I can under standing orders. To give you any more, I will have to call the ED doctor on the radio. Would you like more pain medicine?”
If they say yes, I call. Simple as that.
My last three cases (all presenting with 10 of 10 pain):
A 50-year-old two hundred and twenty pound female with a spontaneous hip dislocation received 20 of morphine with one milligram of Ativan on top (at the suggestion of the on-line doctor).
An 83-year-old one hundred and fifty pound man with an anterior shoulder dislocation received 14 milligrams of morphine.
An 82-year-old one hundred and sixty pound female with an obvious hip fracture received 15 milligrams of morphine.
In each case, I called and got permission for the additional dosing from the ED physician. And in each case, the ED nurse when I told her the amount of morphine I had given repeated it aloud with an exclamation point on the end in a voice loud enough for everyone within fifty feet to turn and look at us.
My answer has been the same in every case.
“I didn’t give it to the patient all at once. I gave it incrementally over thirty minutes. I spoke with the physician before giving the final dose, and by the way, the patient is still awake, breathing and in pain.”* I wanted to say IN PAIN, but I have better manners.
*although admittedly less than when I arrived.
I know from comments on previous posts that there are some systems out there that our more aggressive than ours and allow up to from 20 to 40 mg on standing order.
We will be meeting as a region shortly to review our current guidelines and I will be pushing for us to be able to give an additional 0.5 mg dose on standing order beyond what we currently do, thus setting our total maximum on standing orders to 0.2 mh/kg or 20 mgs. Keep pushing those limits out a little at a time.
In another note, while fentanyl has been approved in our protocols for the last year and a half, our service will just now be receiving it starting in a few days. I am anxious to try this drug out on my patients and see how it compares to morphine. The medics I know who have been using it, almost universally prefer it to morphine due to its quicker onset.
I also want to add that I regularly discuss my pain medicine adventures with ED doctor friends and other paramedics looking for feedback. I did recieve this caution from one about the problem giving too much morphine to an elderly patient with a dislocation who will likely need procedural sedation in the ED in order to relocate the dislocation. Having that much morphine on board makes his decision on what drugs to give the patient a little more difficult and will require a closer monitoring of the patient. This is one reason he is such a strong proponent of fentanyl because the fentanyl doesn’t last as long as morphine enabling him better control in the ED in these cases. That being said, he stressed if the patient is in severe pain, you need to take care of that pain. I followed up on the patient with the shoulder dislocation. Over the next two hours the patient recieved three milligrams of dilaudid in the ED and then 5 of valium for the relocation attempt that was successful, greatly reducing the pain.