We are there for the good of the patient, not for the good of the protocol, not for the good of the medical director, and not for the good of the company.

- Rogue Medic

Burns and Pain and Little Kids

The ambulance is already on scene, bringing the little girl and mother out to the ambulance.

Everyone is looking to see what is going on.

Who could be making so much noise?

The noise is not from the ambulance, not from my truck, not from the police cars, nor from any of the emergency noise makers you would expect.

The noise is from the little girl screaming.

Piercing all sound barriers.

All except one.

We place her in the ambulance ask a couple of questions and then start to the specialty hospital that is both a burn center and a pediatric center. We have too many people on the ambulance – Dad up front, 2 EMTs in back with me, Mom, and our little patient. We’re not really at clown car capacity, but the amount of room is not as comfortable as I would like. Rather than be able to spread out my gear and have easy access to it, I need to pass my bags to the EMTs, so they can pass individual items back to me. On some calls this might be a problem, but this will not be one of them.

Mom is sitting across from me, on the other side of her daughter, holding her daughter’s hand. Looking for someone to ease her daughter’s pain. All of the right people showed up with all of the right equipment to do just that. Everything is working as it should when a well trained group of people, who do this on a regular basis, work together.

Mom is feeling so much guilt for her inability to protect her child. Feeling she has betrayed her child – allowing a curious child, and what healthy child isn’t curious, allowing a curious child to see the handle of a pot calling to her.

The handle is tempting her from over the edge of the stove.

It is making funny noises.

What is going on there?

What child doesn’t want to know?

Well, Mom feels guilt for not being there to stop the inquisitive climbing, the reaching for the pot.

Guilt for not being able to have the scalding, boiling water land instead on Mom and spare her daughter.

Guilt for not keeping up with the developmental progress of her daughter, ever exploring the unknown.

Guilt because today the monster was not just an imaginary one in the closet.

And she was not able to protect her daughter.

The little girl did pull the pot down onto her chest, onto her arms, onto her legs, and onto her diaper.

Mom deserves praise for being smart enough to immediately remove the diaper and prevent far more serious burns from developing. We forget that diapers are designed to trap water. Trapped boiling water on the groin is sometimes overlooked in the panic following a scalding of a child.

The screaming is not likely to be any worse if the child’s groin is being scalded, but the pain she feels could be worse.

Her expression of pain is 10/10, right now. Can her pain get any worse?

Yes, her pain can get worse, but how can she express it any differently, any more clearly?

She probably cannot.

But Mom has prevented the worst part of the scalding through her quick action of removing the diaper. Telling Mom this does nothing to ease her pain or her daughter’s pain.

I call OLMC (On Line Medical Command) for orders for some morphine to help ease the baby’s pain. Morphine is not the best drug for this, but it is traditional and medicine is enamored of tradition. Fentanyl is much safer.

Dr. No Narcs answers the OLMC phone. Inside I cry, but even he would not force this patient to continue to suffer extreme pain, would he?

He tells me not only does he not want me to give any morphine, he does not want me to start an IV, but he does want me to keep sterile dressings on the burns. He is board certified in both emergency medicine and internal medicine. All of that education is wasted when it is not used. He doesn’t seem to know a thing about EMS or a patient’s experience of pain.

Calling another hospital for medical command, after you have been refused orders, is discouraged. Since it would be irresponsible of me not to call the destination hospital, where they do not know me, I call. They are no better than Dr. No Narcs.

Unknown Useless Doctor – We’ll manage the pain when you get here.

RM – But she’s in severe pain. Can’t you hear her.

UUD – I do not appreciate medics questioning my orders.

RM – I’m not asking for the orders for me – I’m not the one in pain.

UUD – Bring the child in and leave the medicine to the doctors.

I am having a Richard III moment, but I have no kingdom to offer in exchange for a competent doctor. My patient suffers tragically.

We arrive at the hospital (a burn center and a pediatric hospital). By now the little girl is having periods of unresponsiveness, not that I attempt to awaken her – she is already receiving far too much painful stimulus.

Her periods of unresponsiveness are lasting about 5 seconds at a time. She is exhausted. Whatever energy she had that might have been needed to help her heal, has been dramatically diminished.

The doctor, one of the pediatricians, is going to start an IV personally. The doctor is not exactly trusting the ED staff to do this. I am reminding the doctor about the obvious pain. Should anyone need any reminding with a screaming child?

The doctor states that oral acetaminophen with codeine will be enough.

The area is overflowing with university medical centers, yet physicians who understand pain management are as scarce as hen’s teeth.

The doctor gets the IV on the first try, but the little girl pulls away before it is secured. Two more unsuccessful attempts, then success. Before securing the line, the doctor gives one milligram of morphine. By now, the little girls unresponsive periods have increased to 15 seconds long and about a minute apart.

Now, over an hour after pulling the pot off of the stove, she has some relief. With the morphine she sleeps. How appropriate. How inappropriately delayed.

Oh, don’t pretend you know what is best for this child – what if she stops breathing?

She would have to stop thrashing about violently for respirations to even begin to be a concern. We are having trouble just keeping her on the stretcher, never mind keeping sterile dressings on for even the 8 second bronco riding time.

Stops breathing?

As in the respiratory rate drops down from 60 breaths per minute to 50 breaths per minute?

Or to 40 breaths per minute?

That really would be a problem؟

This child is nowhere near respiratory arrest.

If there should be any question about the respiratory drive, and the medic misses the signs, what would make anyone think that Mom will be anything other than alarmist about any problem with her baby’s breathing?

She is feeling under-protective and feels a need to atone for that. Will she remain silent?

What about the medic, only an arm’s length away from the patient?

How could a competent medic miss dangerous respiratory depression in this child?

The only way this can be justified is if you allow dangerous medics in the system.

Do we knowingly endanger the population of patients by scattering hand grenades with faulty pins among the people they turn to for protection?

That would be completely wrong, but does not seem to be uncommon.

Mom felt guilt for not protecting her daughter from a foreseeable dangerous situation.

I feel guilty for being a good little Nazi and just following orders.

Orders designed to allow medical directors to feel comfortable endangering patients and allowing them to delude themselves that they are protecting those patients.

I have betrayed my patient by following the orders of not one, but two different indifferent medical command doctors who refused to allow for the treatment of a tiny patient – a patient they could clearly hear over the phone.

Hippocrates would never have approved of this.

To have the means of easing a patient’s pain, but to refuse the treatment to the patient.

Why is OLMC sometimes the sound barrier impervious to all entreaties?

I continue this and expand on some of the comments in:

How EMS “Manages” Pain.

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Comments

  1. That is INEXCUSABLE of those physicians to prolong that little girls suffering. INEXCUSABLE. They need to be reported to hospital administration, DHS, JCAHO and their respective boards.Be an agent of change, work through your agency to develop protocols to administer pain relief in the field.An I would report those guys, I really would. I hope mom and dad go to hospital administration.INEXCUSABLE.

  2. I agree that it is inexcusable (upper case, too).One of the doctors is the director of the hospital’s ED and any complaints about the EMS orders are referred to the ED director. The other hospital is also not known for pain management.The EMS directors do not see this as a problem that is worth making waves over. Since this happened the state has standardized protocols and there are standing orders for reasonable doses of morphine or fentanyl, but the indications are limited.One restriction is:”9. Narcotic pain medication should not be given if:a. Oxygen saturation < 95%b. SBP < 100 for adultsc. SBP < 70 + 2(age in years) for children < 14 y/od. Patient has altered level of consciousness”What was this child’s BP?With burns on arms and legs, there was no way I was going to add a possible route of infection and increase her pain in order to fill out the required part of the chart. Strong equal radial pulses is all that needs to be known. It is obvious from the patient’s presentation that hypotension is not a concern any more than hypoventilation is, but this is the way EMS is handled here.They might also say that there was altered mental status. I agree, but this is a condition that will only improve with appropriate pain management.In at least one of the university hospitals they still worry more about addiction to pain medicine, than they do about pain, when treating terminal cancer patients in the ED. I have talked to JCAHO. They told me that they are not interested in applying the pain assessment and treatment guidelines to EMS – even though the orders come from the hospital and should be seen as extending the hospital’s care to the patient. I have been told that this is changing for hospital based EMS.I used to be on the county protocol board and when I joined, they were adamant that there should never be any standing orders for opioids for anything in their county. Things changed while I was there, but only because one of the progressive doctors pushed for this change. Even that was not much. Until a couple of years ago, no morphine for chest pain without an order from the doctor. Those orders were often limited to 2 mg. Imagine trying that in your ED.Some places are very behind the times, even with a bunch of medical schools turning out doctors.Things are improving a bit.

  3. This is a very unfortunate situation, but one which I am also familiar with where I ride (in Baltimore, MD). I once had a CHFer who was filled to the top…you coul dhear it when you walked in the door. The guy couldn’t get more than a word out at a time, his O2 sat was around 70, and he generally just looked like he was about to give up. As a matter of fact, on arrival at the hospital, he promptly did give up trying. I called the hospital to request NTG, lasix, and albuterol. I was turned down for all but NTG, and still, only a total of 1.2mg (this was before we had CPAP, captopril, or the protocols to administer high dose NTG). As I said, he stopped breathing shortly after we arrived at the hospital. This was another doctor who is notorious for turning down just about anything you ask for. If you get her on the box, it’s best to just claim poor reception, hang up, and try somewhere else. She’s also turned me down for morphine, but not for anything as serious as what you had. Fortunately, we can now give morphine without consult (except for chest pain). Yes, there are situations where doctors know best and probably should turn down requests. But most of the time, the medic hopefully has some idea of what they’re doing. If doctors aren’t going to learn to cooperate with EMS, we might as well just have a bunch of EMT’s out there.

  4. The ignorant restrictions on NTG in CHF continue to be a problem. IV NTG would be much more effective, but doctors who limit NTG to 3 do not seem to understand how to use nitrates. Or they are so distrusting of the medics’ abilities that they put these killer restrictions on treatment. Either way, it is bad medicine.”Yes, there are situations where doctors know best and probably should turn down requests.”That assumes that the harm caused by OLMC (On Line Medical Command) requirements is less than the benefit. I do not think this is a reasonable thing to assume. OLMC requirements allow medical directors to approve dangerous medics to treat patients and feel that they are protecting the patients by requiring a phone call for permission for “dangerous” treatments. This is an irresponsible abuse of the trust of patients.

  5. Scott, Hoping the medic knows what they are doing is one of the first things that need to change. We shouldn’t “hope” our co-workers can manage a patient. Especially a critical one. Some people should not be practicing. period. It is up to where we work and our medical directors to weed out those that should not be on the street. Our patients don’t hope we can help them. They expect it. We as medics and our directors should expect it as well.Second we as providers need to be absolutely sure that we are giving the best radio report we can to paint a clear picture for the doctor on the other end of the line. While we all have docs in our areas who do not want to give orders for anything or provide pain management, we still have to give our best inside the flawed OLMC system. We owe it to our patients to not give up. They (the doctors) only know best if we give them all the pieces we can. I agree that with holding pain meds for this patient was completely innapropriate and inexcusable. Unfortunately it is a reality that we live with everyday.

  6. Gertrude, Very well put.

  7. I am surprised that mom wasn’t white knuckled with a vise like grip on your Rogue Mediciles demanding some analgesics! (Imagine the OLMC doc trying to convince mom that it was ‘dangerous’ to administer pain medicine to her little girl.)I can’t imagine the scenario where a doc encounters a child in a room in similar pain and decides to wait x minutes to do something about it.

  8. Vince,You’ve dealt with the same doctors. Mom was probably feeling too guilty. She may not have known anything about what we carried for pain relief. One of the things I should have done is told Dr. No Narcs that we would be transporting to his facility if he did not give orders for some morphine. We did not have Fentanyl, then. Clearly her pain and our inability to keep sterile dressings on the burns (as ordered by OLMC) necessitated diversion to the closest facility. :-)

  9. “He is board certified in both emergency medicine and internal medicine. All of that education is wasted when it is not used. He doesn’t seem to know a thing about EMS or a patient’s experience of pain.”Some people are just educated above their intellect. All too often, Doctor is included in their name. Gary

  10. It seems that some act as if having become a doctor, or attending, or acquiring board certification, . . . is the equivalent of being infallible.To try to convince them to improve treatment of patients, you present them with evidence of safety, effectiveness, and the experience of years of safe use in other EMS systems. They respond with fairy tales designed to scare little children.Then there are some excellent doctors out there working to change this.

  11. Your post silenced a room full of know-it-all 20 year old EMTs hyped up on sugar and caffeine for a good five minutes. Not much makes them take a moment and think. Keep it up, you’ve encouraged several people to think twice and question The System.

  12. Usually, just pulling out the paddles and charging them up keeps them quiet for a while.Neither one seems to last all that long, though.If I can get people to think, then I am doing my job. Regardless of whether they agree with me.

  13. That is really fucked up – even though the kid may not remember the burns as she gets older, you should consider reporting these doctors to the AMA – all patients have a right to have the pain treated. I’ve had very severe burns while camping that couldn’t be treated and I know how bad that hurt – so if I were in your shoes I think I would have violated protocol and given her something to ease the pain but I also live in chronic pain daily and know what it’s like to suffer. Off topic, You have a cool blog, I found it from your pain management post (that cited this post) – since I’m looking into better ways to treat my extreme flairs that send me to the hospital almost every month lately. I want to see if I can just have an EMT give me a shot of morphine/fentanyl, etc. instead of going to the hospital and waiting for 2 hours just to receive a milligram of hydromorphone (if I’m lucky) – split into 2 half milligram doses – even with a documented painful condition – then being discharged rudely when still in pain.

  14. AJ,This was quite a while ago. Protocols were much less permissive, then. If I had violated protocols on that job, I would have been fired and probably would have the ED medical director trying to get my medic certification pulled. This was not really that unusual, back then. There are still places where this occurs. Calling 2 different medical command facilities got me the same orders – no pain medicine for severe pain. There are still a lot of people with very paranoid approaches to pain management, but things are slowly improving. The newer ED doctors tend to be much more comfortable with low and moderate doses of pain medicines. The high doses still scare almost everyone.As far as getting an EMT (it would have to be a medic to give pain medicine) to give you a shot for pain, then leave. I don’t expect anybody to be doing that any time soon. The DEA would have a fit about patients receiving narcotics, but not being seen by a physician. Hydromorphone is Dilaudid and 1 mg is equal to about 8 mg of morphine. This is an amount that still scares many doctors, even though there is no good reason for their fear – as long as they have competent medics working for them. But that is the problem, the doctors most likely to withhold pain medicine are the doctors most likely to be encouraging incompetence, e.g. creating EMS in their own image.

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