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Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia

Fri, 27 May 2011 06:30:46 -0400 by
–ResearchBlogging.org

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Also posted over at Paramedicine 101 (now at EMS Blogs) and at Research Blogging. Go check out the rest of the excellent material at these sites.

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On the most recent episode of the EMS Research Podcast,[1] Harry Mueller, Bill Toon, and I discuss a recently published paper examining what effect prehospital fentanyl has on hypoxemia or on hypotension.

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This study’s objectives were to assess for association between prehospital fentanyl administration and the occurrence of either of the following: hypotension, defined as a drop in systolic blood pressure (SBP) to below 90 mm Hg in a patient at least 5 years of age, or hypoxemia, defined as a drop in peripheral oxygen saturation (SpO2) to below 90%.[2]

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There were 500 patients and many of them received more than one dose of fentanyl. Several received 6 separate doses of fentanyl.

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Even with so many doses given, the mean dose and maximum dose were not that high.[3]

The median dose of fentanyl per administration was 1.1 µg/kg (IQR 0.8–1.4; range 0.25–3.5 µg); the mean dose was 1.1 µg/kg (SD 0.46). Expressed as a total dose per patient (i.e., summing all doses in a given patient), the median dose was 2.5 µg/kg (IQR 1.7–3.9) with a mean of 3.0 µg/kg (SD 1.8).[2]

1.1 µg/kg per dose.

The maximum single dose is unusual and is not explained. range 0.25–3.5 µg which should be /kg.

How did one patient receive such a large single dose – 3.5 µg/kg? The thing that makes the most sense (if this was a dosing error) is that this was a small pediatric patient. I carry fentanyl in syringes that contain 100 µg in 2 ml (50 µg/ml), but they might carry vials that have a larger volume. for example, below is packaging for 250 µg in 5 ml (also 50 µg/ml). If an entire vial were given to a 140 kg patient, that would be a dose of 3.5 µg/kg.

Is that what happened?

I don’t know – and that is presuming that this is a dosing error, which may not be valid to presume.


Image credit.[4]

I like the idea of carrying 10 mg morphine syringes and 100 µg fentanyl syringes. The total dose of each syringe is roughly equivalent in its effect on a patient. Except in very unusual circumstances, even a full 10 mg morphine, or 100 µg fentanyl, is not going to produce significant problems – and that is assuming that there is no judgment going into the dosing of patients.

Should we assume that there is no judgment going into the dosing of patients?

No, but I will get back to this in a little bit.

If this was not a dosing error, it is extremely aggressive dosing. I am comfortable giving a bit more than 1 µg to otherwise healthy trauma patients or burn patients, but I will at least give this a couple of minutes to have some kind of effect and reassess the patient before giving more. Similarly, with morphine, I might give up to 0.15 mg/kg to these same patients. 3.5 µg/kg is about three times higher than I am comfortable with.

Does that make the dose inappropriate?

Without knowing the specifics, we really cannot tell.

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Should we assume that there is no judgment going into the dosing of patients?

There are prior data to support the safety of appropriately administered opioids, including fentanyl. The study of Kanowitz et al., although more methodologically rigorous than most reports, is typical in its demonstration of safety: of 2129 patients receiving an opioid (fentanyl), only 12 (0.6%) had a medication-related vital sign abnormality and an intervention was required only once (in a patient who had no sequelae)(8) [2]

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What about in this study?

It is noteworthy that, although the study HEMS program’s fentanyl protocol does not proscribe use of the drug in hypotensive patients, the crew are required to use the agent judiciously (in other words, at the lower end of the recommended dosage range). This means that the safety of fentanyl as demonstrated in the current study may be related to more conservative dosing in unstable patients, but the parallel message is that experienced EMS crews are able to exercise judgment in determining which patients should receive cautious drug dosing.[2]

Should we assume that there is no judgment going into the dosing of patients?

experienced EMS crews are able to exercise judgment in determining which patients should receive cautious drug dosing.

The authors of this study do not come to the conclusion that EMS crews cannot make dosing decisions independently. The authors come to exactly the opposite conclusion.

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What about the hypotension and hypoxemia?

New hypotension (i.e., post-fentanyl SBP < 90 in a patient at least 5 years of age, with pre-fentanyl SBP at least 90) was seen in 28 administrations (2.7% of 1055 administrations, 95% CI 1.8–3.8%).[2]

Vital signs were measured within ten minutes of each dose of fentanyl (usually within 5 minutes).

Does hypotension developing so soon after fentanyl mean that the fentanyl caused the hypotension?

No.

It is possible that fentanyl did cause the hypotension.

It is possible that fentanyl did contribute to a drop in the blood pressure.

It is possible that fentanyl did not affect the blood pressure at all.

It is possible that fentanyl had the effect of increasing the blood pressure, but that increase was outweighed by something else causing a greater drop in blood pressure.

We do not have enough information to determine what effect fentanyl has on blood pressure in these patients, but we no longer have a good reason for expecting that fentanyl will produce hypotension.

There are many possible side effects of fentanyl, but even in hypotensive patients we should not expect any sudden deterioration in blood pressure with judicious administration of fentanyl by competent EMS personnel.

The authors do make one error here. They use the total number of administrations of fentanyl in their calculation of the rate of new hypotension to come up with 2.7%.

Overall, in 45 cases (4.3% of 1055), fentanyl was administered to patients who were hypotensive.[2]

Those 45 patients should be excluded from the calculation of new hypotension. Therefore the rate should be 2.8%, rather than 2.7%. This does not change the conclusions in any way. This is just a technicality.

What about those 45 patients who were hypotensive before receiving fentanyl?

In 53% of these cases, hypotension (predictably) remained after the opioid was given—but in 47% of cases in which fentanyl was administered to hypotensive patients, the next SBP exceeded 90.[2]

About half of the patients who were hypotensive before fentanyl were not hypotensive after fentanyl.

While 45 is a small number of hypotensive patients, how many of us would like to have a treatment for hypotension that is effective on half of our patients?

I am only partly kidding.

We do not know what other treatments were being provided, but how many of these patients may have had changes to their vital signs due to severe pain?

We presume that fentanyl will make vital signs worse, but that is a mistake. We may make less of a mistake with worrying that morphine will cause hypotension, based its potential for histamine release.

What was the effect of fentanyl on vital sign abnormalities in the Kanowitz study of fentanyl?

Of the 2,315 patients who received fentanyl in the field, 66 patients had a vital sign abnormality. Of those 66 patients, three were excluded because they received a sedative in addition to the fentanyl. There were 46 patients who were excluded because their vital sign abnormalities occurred before the administration of fentanyl. Of the 46 patients who had a vital sign abnormality before the administration of fentanyl, 38 patients’ vital signs improved after the administration of fentanyl, eight patients’ vital signs remained the same, and none worsened.[5]

Of the 46 patients who had a vital sign abnormality before the administration of fentanyl, 38 patients’ vital signs improved after the administration of fentanyl, eight patients’ vital signs remained the same, and none worsened.

It is possible that fentanyl is improving vital signs by decreasing pain.

The problem is that so many of us do not take the pain of others seriously, so we do not expect pain to lead to problems with vital signs.

Does the improvement in vital signs so soon after fentanyl mean that the fentanyl caused the improvement in vital signs?

No.

It is possible that fentanyl did cause the improvement in vital signs.

It is possible that fentanyl did contribute to an improvement in vital signs.

It is possible that fentanyl did not affect the vital signs at all.

It is possible that fentanyl had the effect of worsening the vital signs, but that worsening was outweighed by something else causing a greater improvement in vital signs.

We do not have enough information to determine what effect fentanyl has on vital signs in these patients, but we no longer have a good reason for expecting that fentanyl will frequently produce bad vital signs. Fentanyl was much more likely to be followed by an improvement in vital signs.

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We almost forgot about hypoxemia. Hypoxemia is an even bigger concern than hypotension.

What effect did fentanyl have on hypoxemia?

Assessment of the 522 administrations in 279 non-intubated patients revealed no difference in the mean SpO 2 readings before (98.8%, 95% CI 98.5–98.9) and after (98.6%, 95% CI 98.3–99.0) fentanyl administration. There were no instances of hypoxemia in these non-intubated patients receiving fentanyl (one-sided 97.5% CI for 0/279: 0–1.3%).[2]

Not even a single instance of hypoxemia.

None.

This was such a big concern that one of the helicopter services near me (based in a university hospital) only permitted flight crews to give fentanyl after a patient was intubated.

No tube – no fentanyl.

Myth busted.

We do need to be cautious about the administration of fentanyl to any patient. We should continually monitor ECG, SpO2, blood pressure, respiratory drive, and level of consciousness. With higher doses we should also continuously monitor waveform capnography.

Fentanyl is safe in the hands of competent EMS providers.

Fentanyl should not require medical command contact for any dose.

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Go listen to the podcast.

Contact EMS Research at:
603-397-0367
emsresearchcast at gmail dot com
EMSResearchCast on Twitter
EMS Research at FaceBook

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Footnotes:

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[1] Fentanyl Study: EMS Research Episode 9
EMS Research Podcast
Podcast

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[2] Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia.
Krauss WC, Shah S, Shah S, Thomas SH.
J Emerg Med. 2011 Feb;40(2):182-7. Epub 2009 Mar 27.
PMID: 19327928 [PubMed – in process]

Full Text PDF Download at medicalscg.

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[3] Mean, Median, Mode, and Range
Purplemath
Article

It is good to be clear on what the meaning of the terminology. This has the simplest explanation I found in a very brief search.

The “mean” is the “average” you’re used to, where you add up all the numbers and then divide by the number of numbers. The “median” is the “middle” value in the list of numbers. To find the median, your numbers have to be listed in numerical order, so you may have to rewrite your list first.

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[4] FENTANYL CITRATE injection, solution
[Baxter Healthcare Corporation]
FDA Label
DailyMed
How Supplied
Free Full Text FDA Label from DailyMed with links to Free Full Text PDF Download.

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[5] Safety and effectiveness of fentanyl administration for prehospital pain management.
Kanowitz A, Dunn TM, Kanowitz EM, Dunn WW, Vanbuskirk K.
Prehosp Emerg Care. 2006 Jan-Mar;10(1):1-7.
PMID: 16418084 [PubMed – indexed for MEDLINE]

Free Full Text PDF Download from MSTC.

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Krauss, W., Shah, S., Shah, S., & Thomas, S. (2011). Fentanyl in the Out-of-Hospital Setting: Variables Associated with Hypotension and Hypoxemia The Journal of Emergency Medicine, 40 (2), 182-187 DOI: 10.1016/j.jemermed.2009.02.009

Kanowitz A, Dunn TM, Kanowitz EM, Dunn WW, & Vanbuskirk K (2006). Safety and effectiveness of fentanyl administration for prehospital pain management. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 10 (1), 1-7 PMID: 16418084

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Filed Under: Critical Judgment, EMS Research Podcast, Fentanyl, Heresy, Mythology, Pain Management, Paramedicine 101, Research Blogging

Up to a Maximum of X Times vs. Titration

Fri, 11 Jul 2008 00:30:00 -0400 by
Over at Ridin’ the Bus, Gertrude was writing Who’s teaching the teachers? Well, my answer is that the teaching jobs are often as political as the desirable EMS jobs. Squad Y is a bunch of people friendly with So-and-So. Squad B is a bunch of people friendly with Whojamacallit. Whether these are 911 jobs, critical care jobs, flight medic/nurse jobs, or anything else does not matter. There is more of an old boy network involved than a critical examination of the qualifications of a job candidate. Teaching is no different.

The current teachers are not necessarily those who excelled in medic school, or EMT school, when they attended. They might not have learned things all that well, when they were in school. The instructor may have modified his understanding since then, but that does not mean that it was for any medical reason. A lot of what is taught is pure speculation.

I described this in several posts A, B, C, D, and E. I reference it in several others. We are poorly educated. The educators often do not know what they are doing well enough to be teaching it.

An excellent example of this is cardioversion. I have never seen anyone else do a good job of teaching cardioversion. That does not mean that it does not happen, but it is not encouraging that I do not see it taught well. ACLS (Advanced Cardiac Life Support) encourages us to just review the material, since the students are already supposed to be familiar with everything. How many nurses going to their first ACLS class have any experience with cardioversion? This is not something that you learn to do well from a book or a blog. You learn it by using the paddles, turning on the synchronizer, and delivering shocks to a mannequin or to a patient. Too many people learn, during their first cardioversion, that they never really understood cardioversion.

Anyway, the topic of Gertrude’s post was the rules that are taught to us. Her example is when a student asked her for the maximum number of times a patient can be suctioned.

Think about this.

Why do we suction patients?

We suction them because there is something in the airway that may interfere with ventilation. It may be a potential obstruction. It may be a partial obstruction. It may be a complete obstruction.

As long as we do what we can to maintain oxygenation, there is no maximum. For the complete obstruction, there is no reason to pause and ventilate in between suction attempts, or to limit the length of suctioning, unless there is the possibility that you have cleared, or partially cleared, the obstruction.

One of the other instructors had given them a number. What is a good number for this? 3? 5? 23? The patients weight in kilograms, divided by their SpO2 percent, multiplied by the number of synapses actually transmitting information in that instructor’s brain?

How about until the portable battery runs out? But remember there are other ways of creating suction – a large syringe, a bulb syringe from the OB kit, scooping things out of the airway, gravity, a vacuum cleaner in the residence. Who really cares how you do it, if you are able to provide the airway the patient needs?

Why do we feel the need to have a number? A limit on what we can do?

People like externally imposed limits. The idea of being responsible for making intelligent decisions is something that many people flee from.

“Responsibility? Just tell me what I have to do to avoid getting in trouble.”

“As long as I follow the protocol, I won’t get in trouble.”

Of course, if the protocol does not apply to your patient, or if you follow the wrong protocol (because you ignored assessment in favor of memorization of protocols) you might kill your patient in your devotion to keeping out of trouble.

Maximum of 3 NTG (NiTroGlycerin, overseas GTN – GlycerylTriNitrate).

Why?

Most likely because the AHA wants you to switch the patient to IV NTG as soon as possible. Not exactly common in the prehospital setting, but a very good idea. NTG is a drug that needs to be titrated. A maximum number prevents titration, so people teaching these maximums should not be teaching. Titration is adjusting the dose based on the response of the patient. Almost all EMS drugs need to be titrated.

Does a response mean that you stop? No, but you take that information into consideration in your continuing doses. Sometimes it will mean to stop. NTG + Syncope is more than a subtle hint to stop NTG. After blood pressure returns, then you may resume cautiously (perhaps after running a liter into the patient) or you may decide not to give any more, but initially your response should be to stop.

Atropine is not a titration drug. Fast push, a minimum adult dose of 0.5 mg and a maximum dose of 0.03 mg/kg if stable, 0.04 mg/kg if unstable. With atropine, you may get the opposite result of what you want, if you give it slowly or if you do not give enough. Another non-titration drug is adenosine. Also fast push. Maximum of 3 doses – 6 mg, 12 mg, and another dose of 12 mg. Glucagon is another drug not generally titrated (many places do not even carry more than one dose).

Some titration drugs:

Oxygen – titrate to adequate oxygenation.

Dextrose 50% in Water – titrate to adequate saccharinity.

Dopamine and dobutamine are given as drips, the dosage formula is for calculating a starting dose and for understanding the maximum dose rate, which does not mean that you stop, only that you stop increasing the dose rate.

NTG – I have given over 50 sprays (over 20 mg) to a single CHF patient on one call and the blood pressure never dropped below 200 mm/hg systolic. Maximum of 3? Not a chance.

Albuterol (Salbutamol overseas)- if the patient is not able to breathe adequately, we continue giving albuterol, but we add other beta 2 agonists, maybe some magnesium and methylprednisolone. There are some who will even tell you that you may not give albuterol to a tachycardic or hypertensive patient, since it is not completely selective for beta 2 and might make things worse. Yes, it will stimulate the heart to work harder, but if it opens the airways, the pressure and heart rate will come down in spite of that stimulus. If it doesn’t open the airways, the side effects are not the patient’s primary concern, not even a secondary concern.

Fentanyl/dilaudid/morphine – no minimum dose and no maximum dose. Only the response to treatment matters. No maximum of 6 mg, or 10 mg, or 20 mg, or even 100 mg of morphine (about 60 mcg/100 mcg/200 mcg/1 mg for fentanyl; 0.75 mg/1.25 mg/2.5 mg/12.5 mg for dilaudid). Anyone who tells you otherwise is a liar and/or incompetent.

Midazolam/lorazepam/diazepam – no minimum dose and no maximum dose. Only the response to treatment matters. No maximum of 5 mg, or 10 mg, or 20 mg, or even 100 mg of midazolam . . . .

Diltiazem is a slow push medication that has standard doses (0.25 mg/kg for the initial dose and 0.35 mg/kg for a repeat). If you are giving it slowly it isn’t just to minimize the side effects, but also to observe for side effects that would discourage you from continuing with the dose. Diltiazem is often given to little old people, who may not give much warning before dropping their blood pressure significantly. I like to keep them sitting up and talking to me while I slowly (over 5 minutes, not the recommended 2 minutes) push the diltiazem. If they are sitting up, the part of the body most likely to show signs of decreased perfusion is the brain – sooner than a repeat blood pressure, sooner than skin sign changes. If the behavior changes in any way, I stop and I do not give any more until after I have satisfied myself that this is not a sign of an adverse reaction. I can always give more later, but most likely it is an adverse reaction.

Naloxone – no minimum dose and no maximum dose. I like to give 20 mcg to 40 mcg at a time. Response is what tells me when to stop.

These are just some of the drugs that are only appropriately given when titrated.

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By Rogue Medic
Filed Under: ACLS, Adenosine, Airway Management, Assessment, Atropine, Cardioversion, Critical Judgment, Fentanyl, GTN, Heresy, Math, Midazolam, Morphine, Naloxone, NTG

How EMS Manages Pain

Tue, 20 May 2008 14:13:00 -0400 by

In my last post Burns and Pain and Little Kids, I wrote about a case of bad pain management.

The comments included a lot of discussion of how EMS handles pain management.

I was talking with another medic and the topic of pain management came up. Not the first time that has happened.

One of the problems in EMS is that medics are trained to believe that morphine is some dangerous, magical drug that will sneak in on little cat paws and steal your patient’s breath away. This is told to us by doctors, nurses, and other medics – even non-medical personnel.

We frequently treat respiratory depression in EMS. And we often overreact when we do.

Overreact?

Read Ambulance Driver‘s article on EMS1.com – The Airway Continuum. The comparison between airway management and police use of lethal force is a useful one. Why do we automatically leap to the most invasive approach to airway management?

Conversely, why do we leap to the paranoid expectation of respiratory depression and respiratory arrest, when dealing with pain management?

This is an EMS version of an Urban Legend.

A site that is devoted to finding the truth about urban legends is Snopes.com. We have some people who provide the EMS version of urban legend debunking. AD does that, but he does not go far enough in this article. Not that he might think he exhausted airway management in this one article. AD could go on for days with only a pause for something to whet his whistle. And it would be entertaining, even if he does occasionally plagiarize himself.

Airway management is far more complex than “Intubate ‘Em All and Let Respiratory Sort ‘Em Out.” EMS protocols often do not acknowledge this.

Another problem with the use of morphine is the rush to use naloxone when there is any uncertainty about the patient’s respiratory status. This questionable nature of the respiratory drive should encourage a much more conservative approach. AD discusses this in Naloxone: The Most Abused Drug in EMS.

Pain management is also a far more complex treatment than “One Dose Fits All.” It is also something where “One Drug Fits All,” does not apply. Morphine is commonly used to manage pain, but it is far from a good drug for EMS. The big thing morphine has going for it is Tradition!

But the worst tradition associated with morphine is the dosing. If you are good, you may receive orders to treat an adult with 2 mg morphine. If you are really good you may receive orders to repeat that dose One Time. At least from some OLMC doctors.

The Danger.

The Peril.

The Horror.

There are some big problems with this approach. Pain management is not about rewarding paramedics with aggressive doses for good behavior. These doses that aren’t really even close to aggressive.

Pain management is about providing appropriate care for the patient.

Why is it that paramedics have to fight with some OLMC (On Line Medical Command) physicians for permission to appropriately treat patients?

Why are some doctors such vigorous opponents of appropriate pain management?

Why are some doctors such vigorous opponents of appropriate patient care?

Opponents of appropriate patient care? How can I say that about doctors?

A patient in moderate to severe pain.

A patient with no real contraindications to morphine (if hypotensive, no real contraindications to fentanyl).

A patient who will benefit from the treatment.

A patient too often denied appropriate pain management.

A patient too often denied any pain management.

Now, back to my talk with my friend.

He had a patient with a probable hip fracture. His partner insisted on calling OLMC for orders, even though they have standing orders. OLMC gave orders for 4 mg of morphine – much less than is available on standing orders.

Here are the standing orders for isolated extremity trauma:

ANALGESIC MEDICATION OPTIONS
(Choose one)
Fentanyl 50-100 mcg IV/IO 6,7 (1 mcg/kg)
may repeat ½ dose every 5 minutes until maximum of 3 mcg/kg
OR
Morphine sulfate 2-5 mg IV 6,7
(0.05 mg/kg)
may repeat dose every 5 minutes
until maximum of 0.2 mg/kg
OR
Nitrous Oxide (50:50) by inhalation 8

If we assume that the patient weighs 50 kg (110 pounds), then the standing orders would allow for the patient to receive 10 mg of morphine before having to call command for orders to give any more pain medicine. Not that those orders are likely to take into consideration that the patient is still in pain after 10 mg of morphine – only the “recklessness” of requesting to give more than 10 mg. This is the world of EMS pain management. Pain management isn’t about the patient. Pain management isn’t about appropriate care. Pain management is commonly about treating medical command for discomfort.

If only medical command were familiar with research on EMS pain management, such as I described in Public Perception of Pain Management.

Look at the standing orders again. In the system where he works, the medical director does not allow them to carry nitrous oxide or fentanyl. The medical director does not appear to have any plans for EMS to carry these drugs. The medical director does not encourage the use of the pain management standing orders.

One way that the medics are discouraged is by being labeled “Too Aggressive.”

I once did some ride time with them and was told that they did not want to hire me because some of the medics I rode with said I was too aggressive and others said I was not aggressive enough.

My interpretation of that was that I am Goldilocks’ porridge. Their interpretation was lacking in literary reference. They probably would have labeled me an Upstart.

You can see where the problem is in EMS. When it comes to pain management, it isn’t about patient care. There are several other things that are considered before the well being of the patient is considered. The other things that are considered can all veto the standing orders.

Then there is the problem of pain that is not due to an extremity injury. If the pain is not from an isolated extremity injury, then the pain is categorized as “too risky” to treat.

Not that this is based on research, these are doctors after all, their expert opinion is to “That’s the most foul, cruel, and bad-tempered medicine you ever set eyes on!” and “Look, that morphine’s got a vicious streak a mile wide! It’s a killer!” and “He’s got huge, sharp… er… He can leap about. Look at the breathing!”

It is true, the bunny in Monty Python and the Holy Grail was a killer. At times morphine can produce respiratory depression that can be a killer, too. Just not when well trained medics use it to appropriately treat their patients’ pain. Titrating the dose to the patient’s pain. The well trained medic is the Holy Hand Grenade of Antioch that counters the respiratory depression from a larger than appropriate dose of morphine, or any opioid.

If only the medical director would insist that the medics be competent in the use of the medications that the medics carry, instead of discouraging the use of the unpopular ones.

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By Rogue Medic
Filed Under: Airway Management, Ambulance Driver, Burns, Critical Judgment, Fentanyl, Heresy, Medic X, Morphine, OLMC Requirements, Pain Management, Physician Oversight

Burns and Pain and Little Kids

Sun, 18 May 2008 14:13:00 -0400 by
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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.

.

By Rogue Medic
Filed Under: Burns, Children, Fentanyl, Heresy, Morphine, OLMC Requirements, Pain Management

A Case of Very Rapid Cath Lab Activation.

Sun, 20 Apr 2008 22:36:00 -0400 by
Last week Dr. Wes wrote The Race is On! about an article Saving a Life in 14 Minutes in the Boston Globe.

The article is interesting for a few reasons. It includes a time line, one that does not omit the EMS times. That is what I am going to focus on.

There are a few important questions from the time line.

8:31 EMS is dispatched.

8:34 EMS meets him at his front door. It should only take a couple of minutes to get to the ambulance and start transporting while assessing and treating. A 3 minute response time is good.

8:42 He is wheeled into the ambulance. 8 minutes later. It only took 3 minutes to “hop into an ambulance for the half-mile trip to Rosen’s house moments after his 911 call.“

8:50 The ambulance is en route and notifying the ED of a STEMI. Why not notify when the first 12 lead was done, if the goal is to reduce delays? Although in this case it does not seem to have mattered, not all hospitals will respond as quickly. Yet, another 8 minutes apparently on scene.

8:57 Arrival at the ED.

9:01 Wheeled through ED doors. It took 4 minutes to get from the ambulance to the ED doors? It took less time to drive to the residence and meet the patient at the front door.

Interesting that the only ED contact mentioned is on the radio. The 12 lead ECGs are handed to a cardiology fellow, who works in the cath lab. They go straight through the ED to the cath lab, without stopping. Is there any improvement to the care of the patient that might be contributed by stopping in the ED? No.

The rest of the time line is in the story, but does not relate to EMS as much.

In the ambulance bay, the paramedics perform a second EKG to hone in on the site of the attack. As Rosen’s pain intensifies, they insert IVs and give him morphine and fluids.

They are referring to the interior of the ambulance as the ambulance bay, not the area at the ED where ambulances park. A 2nd 12 lead is nice, but all of this can be done en route – including IVs and drugs. 12 leads can be done while moving. Shaving the chest, if necessary for application of leads, can be done with an electric razor while moving. Using benzoin makes a big difference in getting leads to stick, which can otherwise cause a lot of delays in obtaining a readable 12 lead.

The description of treatment suggests that this was an RVI (Right Ventricular Infarction), since no NTG (NiTroGlycerin in the US, or GTN – Glyceryl TriNitrate elsewhere) was given, but fluids were given (perhaps I am just reading too much into it). There is not much reason to sit on scene for this stuff. Things that do matter are access to the front door of the residence with the stretcher. Was this a reason for delay? Why morphine, when fentanyl is a safer drug – especially with RVI?

If “Kevin and I recognized his heart attack immediately,” why does it take so long to get going?

A study in The Journal of the American College of Cardiology looked at the best practices for improving door to balloon times.

The ideal process (Fig. 1) represents a synthesis of the best practices found in the sample of 11 hospitals and is not meant to reflect the specific process of any single hospital in the study. The door-to-balloon process for patients transported to the ED with a prehospital ECG performed and read by a paramedic before hospital arrival is depicted by Path #1 in Figure 1.

For patients with a pre-hospital ECG indicating STEMI, the benchmark door-toballoon time is 60 min (Fig. 2).

For patients arriving without a pre-hospital ECG, the benchmark door-toballoon time is 80 min (Fig. 3).

No need for telemetry to further delay patient treatment.

Looking at the times:

8:31 response, 8:34 patient contact at front door, 8:42 in ambulance, 8:50 en route with STEMI notification by radio, 8:57 at ED, 9:01 rolling through ED doors and by-passing the ED.

8 minutes from the patient’s door to the ambulance. He met EMS at the door.

8 minutes from entering the ambulance until en route (not sure if I am reading this correctly).

4 minutes from the ambulance arrival at the ED to the ED doors.

There are 20 minutes that could not be completely eliminated, but should be dramatically reduced.

The time from door to balloon is less than the amount of the apparently avoidable EMS delays.

I realize that this article may not be accurate, that these times can never be completely eliminated, that I am reading a bit into this article, but WTF?

Historically, almost all of the unnecessary delays have been in the hospital. Here, it is the hospital that seems to have its act together. Ideal timing does seem to be one thing working in the favor of this patient. He arrived at 9 AM on a week day. The cath lab may have been preparing to take their first scheduled, non-emergency patient of the day and just had to defer that case for a while.

The cardiology fellow is waiting in the ED for the patient. There is little reason for the ED to be involved in the care of this patient. Look at the amount of time saved by the EMS notification of a cath lab patient and by the cath lab staff coming to the ED to take the patient directly to the cath lab.

Let’s add in the 4 minutes that the ambulance was at the ED, but not yet through the doors – 18 minutes door to balloon.

Just to complicate things we can put some butter on the fingers of Dr. Shah, who took just 6 minutes from initiating femoral access to inflating the balloon. How about adding 30 minutes – adding 5 times as long as it actually took. This would still give a door to balloon time of 48 minutes. The AHA and JCAHO goal is less than 90 minutes. This is just a smidge more than half of that goal.

If we can by-pass the ED, difficult if the cath lab team is not in the hospital, the amount of time saved is tremendous. This is not a criticism of the ED – we do the same thing with trauma. The cath lab team needs to be prepared to take the patient right away.

Bradley EH, Roumanis SA, Radford MJ, Webster TR, McNamara RL, Mattera JA, Barton BA, Berg DN, Portnay EL, Moscovitz H, Parkosewich J, Holmboe ES, Blaney M, Krumholz HM.
Achieving door-to-balloon times that meet quality guidelines: how do successful hospitals do it?
J Am Coll Cardiol. 2005 Oct 4;46(7):1236-41.
PMID: 16198837 [PubMed – indexed for MEDLINE]

By Rogue Medic
Filed Under: ACS, Cath Lab Activation, Chest Pain, Fentanyl, Heresy, Morphine, NTG, OLMC Requirements, RVI

OLMC For Good Medics

Fri, 28 Mar 2008 18:37:00 -0400 by


You claim that requiring OLMC (On Line Medical Command) permission to treat patients does not work and actually lowers the quality of medic in a system. You state that Medic X, the example of the dangerous medic, is made worse by OLMC requirements. But, at least, OLMC requirements help the good medics. Let’s call this one Medic A.

Even better, let’s call this example of a good medic – Medic AD – everybody should be able to trust that Medic AD provides excellent care.

OK. Then why wouldn’t OLMC requirements help Medic AD?

You’re asking the wrong question.

The question should be How would OLMC requirements help Medic AD?

Consider it asked.

First – the goal of Quality Control, Quality Improvement, and all other CYA stuff is to improve the quality of the care the patients receive, or to create the appearance of controlling, or improving, or assessing the quality of the care the patients receive.

Focusing QC/QI/CYA on the medic is missing the point – it is about the patient.

How the medic does the job is not the important thing compared to the effect on the patient.

So, how does the need to get permission from OLMC to treat the patient benefit the patient?

The medic, even Medic AD, is not a doctor. He doesn’t know as much as a doctor.

Yes and No.

There are plenty of physicians who just do not understand all areas of emergency medicine.

What ? ! ?

The most obvious example is pain management, such as aggressive fentanyl administration on standing orders.

But these are powerful drugs!

Are there any drugs that a medic carries that are not powerful?

Maybe, but I think I see your point – if all, or almost all, of the drugs a medic uses are powerful, why treat these differently?

That is a good question.

So, what is the answer?

Gosh, I would have to be a psychiatrist – like Dr. Deborah Peel – to be able to diagnose a bunch of physicians without ever having met most of them.

So, you think the problem is psychological?

Not entirely, but there is more than a bit of paranoia about pain medication.

I believe that a lot of this is paranoia and due to a lack of understanding of the medications.

Let me give an example that is typical of what I hear from physicians defending OLMC requirements. The following comments are not at all unusual for conversations I have with medical directors. This written communication just did a wonderful job of bringing so many of them together.

It seems you DO have an opinion, and a sarcastic one at that. But that is beside the point.

Yes, I have an opinion.

Yes, I express it with more than a hint of sarcasm.

You see, you feel comfortable bashing the med control doctors out there because its not YOUR license on the line, and the med control MD hasn’t even seen the patient yet.

So, if I make a mistake the doctor’s license is on the line?

Please, somebody comment about any case where a doctor lost their license because of bad care by a medic. Anyone.

You see what I mean about paranoia?

So, if I make a mistake my license is not on the line?

Why does the doctor need a phone call for permission when it is pain management, but not arrhythmia, or cardiac arrest, or anaphylaxis, or respiratory distress, . . . ?

Paranoia.

Its not YOUR so-called “deep pocket” that the lawyer for the patient who, in so much pain that EMS felt the need to give repeated boluses and later respiratory arrested, are going to go after. While I’m sure in your jurisdiction this doesn’t happen, even in the best of EMS systems there are those few EMS personnel that are either new, inexperienced, or just plain too ignorant to know the dangers of too much analgesia.

Sounds as if I found one of those physicians who is comfortable authorizing medics to treat patients, while knowing that these medics are not safe to treat patients.

OLMC to the rescue!

That will fix everything.

After all, just because they are too stupid to deal with pain management without a magical phone call doesn’t mean they can’t handle life threatening emergencies safely.

If they can’t handle something as simple as pain management – relatively simple if you are well trained – how will they handle a difficult airway?

But, maybe he isn’t the medical director for all of the medics in the system and he just doesn’t trust medics from other organizations.

How many of you out there can truthfully say that you haven’t had at least one case in which a big tough guy had apnea after only a minimum of versed or MSO4?

Again, comments please! Has anyone ever had this happen?

I adjust the dose to match the patient’s weight, underlying health, age, and current condition – then I reassess and determine if more is needed. I keep doing this until side effects discourage further treatment, or I run out of medication (or orders), or the patient is tolerating the pain well. I am always limiting the rate of administration, since most side effects are rate related.

I have never seen this miracle apnea, the doctor describes.

Or one of my most “treasured” memories, the call from EMS who had an unconscious victim and after administering the impaired protocol, called med control for morphine orders because the patient had just “come around and he was screaming in pain”.

Hmm. Unconscious “victim?”

I have addressed appropriate use of naloxone elsewhere.

Maybe a cancer patient treated inappropriately with naloxone?

Point is we are only a voice on the other end of the line sometimes. We cannot see what you see, only hear what you have to tell us.

For a moment, just for a moment, there is reality.

Sometimes we know exactly who you are and what you are all about and we can trust your judgement.

Right here, the doctor states that he does not have a problem with Medic AD using his judgment.

He doesn’t go as far as to say that Medic AD would not benefit from OLMC requirements, but he does suggest that he would automatically give Medic AD the orders being requested.

So, what would be the point of having Medic AD call OLMC before allowing the patient to receive treatment?

OLMC can then hear a familiar, trusted voice and relax.

It is all about the paranoia.

But other times you are simply “that voice over the radio”, the volunteer EMS system from “BFE”, the requested order from an RN who runs into the trauma room asking for morphine for EMS while you are trying to intubate someone,

Doesn’t that sound like a system that works well?

Would you like to be a patient there?

and sometimes, albeit rarely, you are simply another EMS provider who likes to give morphine to everyone, regardless of chief complaint.

This isn’t even using the lowest common denominator to justify OLMC requirements.

This is a medic who makes Medic X look good.

So, why is this medic still working?

OLMC requirements allow medical directors to justify keeping this worse-than-Medic X on the street and pushing drugs.

OLMC requirements endanger patients.

Requiring Medic AD to call OLMC to ask for permission to do what he knows how to do is only interrupting assessment and treatment, delaying patient care, and creating the possibility that an OLMC physician does not give orders that are appropriate for the patient.

The objections from most doctors, who are supportive of OLMC requirements, seem to be most focused on the physician’s ability to control things.

The problem with OLMC requirements is that they are barriers to patient care.

This is about patient care, not physicians’ need for control.

My other posts on OLMC requirements and Medic X are:

OLMC (On Line Medical Command) Requirements Delenda Est

OLMC for President!

OLMC = The Used Car Dealers of EMS?

Fun with explosives – NTG.

By Rogue Medic
Filed Under: Critical Judgment, Dr. Deborah Peel, Fentanyl, Heresy, Medic AD, Medic X, Morphine, Naloxone, NTG, OLMC Requirements, Pain Management, Physician Oversight, Research, Standing Orders

Public Perception of Pain Management

Sun, 16 Mar 2008 05:15:00 -0400 by

From the movie Juno comes this interesting line about pain management:

Doctors are sadists who like to play God and watch lesser people scream.

This received one of the biggest laughs of the movie. One thing about comedy is that there needs to be some truth for it to be funny – stretched to the extreme, maybe, but some truth to it.

Why do so many people believe this about doctors?

Is there any evidence to support this apparently widespread belief?

There are medical command physicians who seem to approach prehospital pain management from the Nancy Reagan perspective – Just say No!

Why?

Is there any evidence that opioids or sedatives are dangerous in the hands of trained medics?

A study in Prehospital Emergency Care (the journal of the National Association of EMS Physicians, National Association of State EMS Officials, National Association of EMS Educators, and National Association of EMTs) strongly suggested that opioids, at least, are safely used by appropriately trained medics.

Pridemark paramedics have administered IV fentanyl under standing order protocols since November 2001. The Pridemark pain management program is very aggressive and field crews receive regular continuing education related to pain management and procedural sedation. The pain management protocol states that an initial dose of 1-2 µg/kg fentanyl can be administered for pain with repeat doses at 1 µg/kg, titrated as needed. The protocol does not limit dosing intervals or maximum total dosing and the contraindications for administration include known hypersensitivity, hypotension, respiratory depression, and myasthenia gravis. The only standing order limitation during the study period was that fentanyl administration for abdominal pain required base contact.[1]

Absolutely no requirement to contact OLMC (On Line Medical Command), except for permission to treat abdominal pain.

That seems very risky!

How can medics possibly make reasonable decisions about the proper amount of medication to use?

Fentanyl is a very powerful drug. In some emergency departments the emergency physicians are not permitted to use fentanyl, since the anesthesia department has convinced the directors of the hospital that it is only safe in the hands of anesthesiologists. Certainly, there is no bias possible in that determination.

If fentanyl is not safe when used by attending emergency physicians, how can it possibly be safe in the hands of lowly paramedics?

How can simple paramedics safely administer this powerful drug on almost unlimited standing orders?

I wish that I worked as a lawyer in that crazy system – or as a mortician!

Well, let’s skip down to the results and find out the death toll.

Wait – we need to find out more about the patients first.

There were 2,315 patients who received IV fentanyl in the field; 186 patients were excluded because they received other medications such as other narcotics, sedatives, or nitrates (see Methods), thus leaving 2,129 patients who received IV fentanyl alone.

The average total fentanyl administration was 118 µg (standard deviation [SD] = 67), with a range of 5400 µg. Similarly, for the subgroup of patients who had their ED charts reviewed, the average total fentanyl administration was 118 µg (SD = 67),
The average dose was 118 micrograms?[1]

Are they trying to tell us that paramedics are starting with small doses, reassessing patients, and giving further doses only when necessary?

That just reeks of responsibility.

I don’t believe it.

Bring on the dead bodies, the malpractice, the horror!

Of the 2,315 patients who received fentanyl in the field, 66 patients had a vital sign abnormality. Of those 66 patients, three were excluded because they received a sedative in addition to the fentanyl. There were 46 patients who were excluded because their vital sign abnormalities occurred before the administration of fentanyl.[1]

66 vital sign abnormalities! Almost 3%. That sounds like something to worry about.

Of the 46 patients who had a vital sign abnormality before the administration of fentanyl, 38 patients’ vital signs improved after the administration of fentanyl, eight patients’ vital signs remained the same, and none worsened.[1]

I guess we can’t really blame the fentanyl for the problems if they happened before the fentanyl, but almost all of them improved after the fentanyl – and none of them got worse.

The medicine helped the patient, that is an interesting concept.

Bring on the less than 1% of problems left.

There have to be some serious problems and a few cadavers in there!

The retrospective chart review of 2,129 patients who were administered fentanyl citrate in the field for pain management revealed that only six patients (0.3%) had a field vital sign abnormality possibly attributed to the narcotic administration. No patients required a reversal or recovery intervention during transport.[1]

No problems outside of the hospital?

Just wait, in the hospital they will have problems!

Of the subgroup of 611 patients who had their ED charts reviewed,[1]

They only reviewed 611 ED charts out of 2,129 field administrations that were reviewed.

They must have been trying to cover something up!

Review of all 2,129 ED charts, instead of only the charts of those patients transported to a single facility, might have revealed more patients with complications. However, the sample subgroup was necessary because 2,129 patients were transported to 19 different hospitals and would have required IRB and HIPAA clearance from 19 individual facilities.[1]

Gosh, that makes sense, out of 19 hospitals they chose one that received 29% of the patients.

A nice busy hospital. They won’t put up with any of this EMS mayhem.

Let’s go back and see the carnage that must have overwhelmed the hospital!

Of the subgroup of 611 patients who had their ED charts reviewed, only seven patients (1.1%) had a vital sign abnormality that could be attributed to the field narcotic administration. The higher rate of vital sign abnormalities in the ED (1.1%) compared with the field rate (0.3%) was anticipated given the short transport times compared with the drug’s duration of action. Only one patient (0.2%) required a reversal intervention in the ED.[1]

Now we are getting some place! A victim!

That patient was an 81-year-old woman with a possible hip fracture who received two doses of 100 µg of fentanyl and developed respiratory depression, which prompted the administration of 0.4 mg of naloxone with an immediate reversal of the adverse effect.[1]

Well, maybe somebody died later – or had other serious complications!

No patient required admission for any complications of pain management, and there were no deaths. These findings demonstrate that fentanyl administration in the field is a safe method for pain management.[1]

But what about the scare tactics that are regularly employed to discourage us from using pain medicines?

Hah! I know what they missed.

They used so little that it didn’t cause any problems, but it also didn’t provide any benefit to the patients.

Where’s the benefit?

The pre-and post-pain-management verbal rating scale scores for all patients who received fentanyl were also evaluated. These data showed evidence of a statistically significant change in verbal rating scale scores after pain management. Clinically, this illustrates an improvement in pain from a categorization of severe to mild and thus supports the effectiveness of fentanyl administration.[1]

From severe pain to mild pain.

What more could you ask for?

Now that we have looked at the results it looks as if they behaved responsibly.

I would even say that they make a good case that it could be copied elsewhere.

Perhaps everywhere.

Why pretend that this study is too small to provide meaningful data; or that the methods were so limited that the results are irrelevant; or that this means it is OK, but only with tight OLMC requirements?

What this really tells us is that not only is there no good reason to limit standing orders (maybe for abdominal pain, which required OLMC in this study), but that there is a significant difference that can be made in patient care.

Why do we have medics treating patients with unsupportable limitations on what they can do without OLMC permission?

If the medics are not capable of providing this level of care, why does the medical director allow such dangerous medics to treat patients?

Why are we denying appropriate care to patients?

Why are we providing less-than-adequate care to patients?

There is no good reason.

Footnote:

[1] Safety and effectiveness of fentanyl administration for prehospital pain management.
Kanowitz A, Dunn TM, Kanowitz EM, Dunn WW, Vanbuskirk K.
Prehosp Emerg Care. 2006 Jan-Mar;10(1):1-7.
PMID: 16418084 [PubMed – indexed for MEDLINE]

I also write about pain maqnagement here:

Pain Management – What is too much?

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By Rogue Medic
Filed Under: Ethics, Fentanyl, Heresy, Humor, Morphine, OLMC Requirements, Opioid, Pain Management, Physician Oversight, Research, Sedation

Pain Management – What is too much?

Tue, 11 Mar 2008 13:54:00 -0400 by

I was looking at some protocols from another area and saw that, although their protocols are basically more restrictive than my too restrictive protocols, the notes about management had some clear and sane advice on the management of narcosis – the oversedation from an opioid.

The notes included more than I clipped, including continuing the presumption that opioids will cause nausea and vomiting. N/V from opioids is almost always due to the rate of administration, not the dose, not the drug, not anything else. At least, that has been my experience.

There are far too many misguided rituals that surround the administration of this supposed Damoclean chemical. It was nice to see a segment of common sense mixed in

Respiratory depression should be treated with oxygen and ventilatory support if necessary.
• Attempt verbal and tactile stimulation to reverse respiratory depression prior to considering
naloxone (Narcan®).
• Administer the smallest possible reversal dose of naloxone to maintain adequate respirations.
Dilute 0.4 mg naloxone in 10cc 0.9% NS syringe and slowly titrate to effect.
The most important part was probably too simple to be written into the protocols.

If the patient is talking the patient is breathing.

This concept seems to be overly simplistic for some doctors, but where is it wrong?

What if the patient is not talking?

Well, if I gave them enough opioid to manage their pain to the point where they are too comfortable and just want to be let alone to nod off AND there is respiratory depression – they are going to stay awake and talk to me for the rest of their time with me. At the hospital they will be encouraged to continue talking while the management of a bunch of morphine is considered by the doctors and nurses. If fentanyl had been the drug used, then the problem should not have been a problem after transferring the patient at the ED. Fentanyl is metabolized quickly and that is why it is the most appropriate EMS pain management drug.

If they are just not interested in talking, are breathing well, and are indicating that my conversation is now their greatest pain, then they can rest; if respiratory depression develops, then they do not have the option of avoiding conversation. If they wish to yell at me to leave them alone, that keeps air moving, too.

If you think that I give enough opioid to prehospital patients to achieve this effect, I do not. I have assisted/observed plenty of procedural sedation in the ED. Not as a replacement for a nurse, just lending an extra hand to do grunt work. Not a lot of anti-nausea medication used in these procedural sedations, either. Just nice slow administration, reassessment, and repeat as necessary.

It is amazing how much you can learn from someone who knows what they are doing. I think medic schools would benefit tremendously from requiring medics to assist with procedural sedation, or in the burn unit, to develop an understanding of what happens with large doses of opioids. The lesson is not to use the same doses, but to see how to manage the patient if the dose is unintentionally too large.

We let numbers scare us to the point where we ignore the patient. This is bad.

Less-than-cheerful nurse: “You gave 26 mg of morphine to that 45 kg little old lady? Are you insane?”

RM: “Which part do you want me to answer first?”

Less-than-cheerful nurse with a sense of humor: “I guess that answers the second question. Why so much morphine?”

RM: “She has 2 Duragesic patches on; had severe pain; and, even with that much morphine, her pain level is still 4/10, increasing to 7/10 with movement. She felt the pain was tolerable when we moved her, we had already spent a lot of time on scene, and we did not want to switch protocols to compartment syndrome. :-)”

The nurse, although Less-than-cheerful, yet in possession of both a sense of humor and the ability to assess the patient and determine the appropriateness of the dose proceeded to do just that. The patient is awake, alert, oriented, and rates her pain as 4/10. Now the nurse is the Less-than-cheerful nurse with an anecdote to share with the rest of the staff. All of this required on line medical command (OLMC) orders, which were fortunately provided by an aggressive ED physician. With the OLMC roulette that we play, you never know how much appropriate care you may be able to provide to the patient.

Well, I didn’t get the patient to the point of being pain-free, but that is not my goal. A tolerable level of pain is all that should be hoped for with morphine. Fentanyl allows for more aggressive dosing due to its much more rapid metabolism. Metabolism is the medic’s friend.

As clarification for the non-medical people Duragesic is a brand name of fentanyl patch that gives fentanyl slowly over a long time; it is absorbed through the skin; even though the fentanyl that is given by EMS is metabolized (used up quickly in the body) quickly, the slow absorption through the patch of the same drug lasts a long time. Fentanyl can be given IV, IM, and by an atomizer spray in the nose, so that an IV is not always needed (little kids, poor veins, …).

Appropriate use of benzodiazepines is not much different from appropriate use of opioids.

Does anybody have any interesting pain management ideas, anecdotes, questions, … ?

I also wrote about this here:

Public Perception of Pain Management

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By Rogue Medic
Filed Under: Fentanyl, Heresy, Morphine, Opioid, Pain Management, Sedation
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