–
In response to my post about elderly patients receiving pain management treatment less often that younger patients, Chris from EMS Patient care advocate One wrote the following.
I too have great success with low dose fentanyl for abdominal pain in the elderly. I was just making a statement to get something going. I too have run into this situation you state about some secret maximum dose. Goes back you one of your quotes “2mg morphine = pain”
Severe pain + 2 mg morphine = severe pain.
You left out the most important part.
2 mg of morphine cannot be expected to have any significant effect on severe pain.
This is a nominal dose. It is a dose in name only.
This allows a doctor to state that the patient received opioid treatment.
It does not relieve pain.
The difference between that dose and no dose at all is so insignificant that it cannot be measured in most patients.
A placebo would be equally effective.
2 mg of morphine is a placebo dose.
–
–
–
–
Not that doubling the dose won’t lead to a game of phone tag with the medical command doctor until the pain is at an acceptable level, or until the medical command doctor becomes scared of the appropriate dose.
–
I hate when in the back of my mind I am wondering if I did my patient a FAVOR or a disservice by bringing them to the hospital.
I point out the options to the patient. I can call a different hospital for orders and possibly receive appropriate orders. I can transport the patient to a different hospital. I can do both.
There is no reason that this does not fall under informed consent, if the patient has the capacity to make informed decisions (or if the patients medical POA (Power Of Attorney) is present.
We are discouraged from calling other medical command doctors for orders, because the doctors are well aware of what the differences in orders are due to –
Whim.
Personality.
Whether the doctor has recently eaten.
How busy the doctor is.
And many other factors that have absolutely nothing to do with how much pain the patient is in before contacting medical command.
These have a lot to do with how much pain the patient is in after contacting medical command.
The orders to refuse appropriate opioid doses to patients are NOT based on any knowledge of medicine.
Doctors who tell you otherwise are idiots, liars, or deluded by their own BS.
This is not meant as a criticism of the doctors who do give appropriate medical command orders. This is only a criticism of the medical command system and of the doctors who do not give appropriate orders for patient care.
–
I sometimes wonder if the ED is afraid of acute pain management.
Some emergency physicians certainly do appear to be afraid of appropriately treating patients with pain. Or maybe they just do not understand pain management.
Many emergency physicians are great with pain management.
–
PS – The stick figures are from xkcd, because my drawing is even worse than my writing. 😳
.
Ah, I am sorry about that.
Though is the “severe” necessary? If 2mg is equal to a placebo, perhaps you mean ANY pain treated with 2mg IV morphine (excluding special patient circumstances) would still have the same amount of pain?
I found it to be an interesting quote. I again apologize for leaving part of it out.
Do we not provide pain management to moderate pain?
How much Morphine is needed to treat someone with “real” pain who has a high tolerance to narcotics?
Do they not deserve proper dosing just because they require higher than the “normal magic pain relief” dose?
“I point out the options to the patient. I can call a different hospital for orders and possibly receive appropriate orders. I can transport the patient to a different hospital. I can do both.”
Good point. I would certainly need to put some big boy pants on. However, I have two hospitals within 20 min. Any others, we are talking about over an hours travel time. I would really be putting myself in the spotlight at the state level doing this.
“Some emergency physicians certainly do appear to be afraid of appropriately treating patients with pain. Or maybe they just do not understand pain management.”
Im not sure all ED doctors that cover the medical control line have any training on being medical control and seem to have no training in pre-hospispital pain managment. Actually I’d say a lot of pre-hospital medicine all together is not understood. Some Docs are great and took interest in what we do and take the time to understand.
I can see how it could make a doctor feel vulnerable to give the online order, but it’s so easy to put up a shield “out of sight, out of mind”.
It is admitted that a lot of doctors in this area really don’t know EMS or how we operate exactly (they just don’t have any training on how to be medical control, who knows).
Also it seems forgotten that bouncing down the road, carefully or not, provokes pain-a lot. They aren’t laying still in a hospital bed. In my short experience as a Medic patients treated with Morphine or Fentanyl the pain relief wears off much faster in the pre-hospital setting than when the same dose is given in the hospital setting.