#1 Pain Management and Comfort Care

The number one treatment change in EMS in the last twenty years is the increased emphasis on painmanagement and comfort care.

Albert Schweitzer said, “Pain is a more terrible lord of mankind than death himself…. We must all die. But that I can save him from days of torture, that is what I feel as my great and ever new privilege.”

Like many I began in EMS with visions of saving lives everyday and then having grateful reunions filmed by the crew of the old TV show, Rescue 911.

Now over twenty years into my career, I know that true life-saving calls are few and far between. And many of those few life-saving calls you really don’t do much more than you are taught:

Show up on scene, find recently collapsed patient, apply defibrillator, shock, feel restored pulse.

Show up on scene, find cool, clammy patient with chest pain, do 12-lead, see obvious STEMI, call hospital to activate cath lab, transport.

Show up on scene, find child in anaphylactic shock, eyes swollen shut, airway closing off, no blood pressure, stick them with epi, and watch them return to their normal self.

Some patients are just waiting there for us to save them.

And on other calls, you can work your tail off, do heroic things and the patient doesn’t make it. It was just their day to die.

Today, I see my job not as a lifesaver, but as a comforter.

My EMT instructor told me the emergency ends when you arrive on scene, or at least that’s what you have to make the patient believe.

Today, my reinterpretation of her comments is this; once I am on scene, the patient is no longer alone. I am there to care about them, to provide whatever comfort and care I can, and to try to keep them safe from further harm.

I do that hopefully with a calm voice, a caring touch, understandable words, and with if they are in pain, with everything from pillows and ice to morphine.

“My great and ever new privilege,” as Schweitzer says, “is to take care of people’s pain.”

I can do that, in one way or another, on an almost daily basis.

When I started in EMS, I did not give morphine at all my first year. I gave it only twice for trauma in the next two years, and then in doses too small to provide relief. This is working in a busy system doing 400-500 ALS calls a year. And for vomiting patient, I never once gave an antiemetic.

“I have to hurt looking at you for you to get morphine from me,” an old school medic taught me when I started.

It’s a new day.

Last year I gave Fentanyl over 50 times, more than any other drug except Zofran, which I gave close to 100 times.

I gave Fentanyl for hip fractures, and ankle fractures, and shoulder dislocations and wrist fractures, for amputated fingers, burns, for kidney stones, and for all sorts of abdominal pains. Did I get scammed a time or two by a drug seeker? Likely I did, but you know what? I don’t care. I can say I didn’t deny anyone in legitimate pain medication for fear they were drug seeking.

Why is pain management important? Because pain is destructive to the human body. Its only purpose is to alert patients to injury to help eliminate the source of the injury and halt damage to the affected tissue. Untreated, pain stresses the body, damages the immune system, hinders wound healing, and can lead to chronic pain. Not to mention the emotional suffering it causes.

“Prompt treatment of acute pain may prevent both short- and long-term deleterious consequences and resultant chronic pain syndromes.” – Pain Management and Sedation: Emergency Department Management, Mace Ducharme Murphy, McGraw Hill – 2006

Nearly ever study ever done on the issue has showed widespread under use of analgesics in EMS systems and emergency departments across the country.

But times are changing.

When I started as a medic, on-line medical control was required to give morphine. Today, for a 220 pound patient, I can give up to 20 mg of Morphine (over 20 minutes) on standing orders and up to 300 mcgs of Fenatnyl. Morphine for abdominal pain was prohibited. Today I can give Morphine and Fentanyl on standing orders.

I may not be able to save a life everyday, but everyday I can treat my patients with respect and dignity, and if they are in pain, I can ease their suffering.

healer

The oldest mission of medical healers is to treat pain. I accept that mission.

And I praise paramedics and EMS systems across the country for coming to recognizie this.

 

***

16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

2. AEDs
3. STEMI Care
4. CPAP
5. Capnography
6. Termination of Rescusitation Guidelines
7. Decreased Use of Lights and Sirens
8. Selective Spinal Immobilization Guidelines
9. Alternative Airways
10. Chemical Restraint
11. No More Lasix
12. EZ-IO
13. Permissive Hypotension
14.Expanded Medication Routes, Less IV Emphasis
15. Narrower Use of Narcan
16. Increased Standing Orders

2 Comments

  • Almost Jesus says:

    This is the reason why I became a paramedic.
    I have yet to save a life in my 3 years of part time work in EMS. What I have done is alleviated suffering. It is very satisfying to be able to give your hip fracture patient 100mcg of fentanyl and be able to move them without pain. The feeling is just as satisfying for me as taking care of a trauma or serious medical patient. It is arguable how much of an impact many of my interventions have when I only have a 5 minute transport time, but when I am able to spend 20 minutes on scene properly medicating a patient for a 5 minute transport, my goal has been met. I take personal pride out of being able to ask my patients “would you like something for pain” and being able to properly medicate them.
    Unfortunately, I dont have the joy of being able to treat pain as well when I am working in the ED. I wish more doctors had the pain management philosophy that has seemed to come to being in the EMS world.

  • doobis says:

    I completely agree on being a comforter and EMS being used to relieve PN and suffering. I have no problem giving PN meds when I believe the PT is “a lot of PN”.
    I do worry about over use of narcotic medications though. Working in FL we have a major prescription PN medication abuse problem which has resulted in many deaths from OD and driving impaired.
    I fear that liberal use of narcotic medications by EMS and ERs tends to let the “genie out of the bottle” and may trigger something in the receiver that starts an addiction. I also worry that too many people rely on narcotics instead of relying on their own personal strength.
    I have seen older generation PTs tend to toughen it out and not want PN medications while younger PTs cry for relief from relatively minor injuries. I just don’t want to be aiding the cry baby mentality or fueling an addiction problem needlessly.

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Peter Canning

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