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

- Rogue Medic

Acupuncture vs intravenous morphine in the management of acute pain in the ED

ResearchBlogging.org
 

What does elaborate placebo mean?

An elaborate placebo is a placebo that does better than a pill, or injection, apparently because the patient has more invested in the belief the placebo will work. An injection of a placebo (saline solution) may be more effective than a pill of real pain medicine because of the ceremony involved in giving the placebo through IV (IntraVenous) access. A placebo that is more expensive tends to have more of an effect than a less expensive placebo.[1],[2]

Acupuncture requires a lot of investment on the part of the patient. A more elaborate placebo might be fire walking. I don’t know of any research on fire walking as a treatment for pain, but I would not be surprised if it is extremely effective.
 

fire walking 1
Image credit. Do not try at home.
 

We know that acupuncture is just a placebo because research shows that sham (fake/placebo) acupuncture works just as well as real acupuncture. Sham acupuncture generally means using toothpicks (rather than needles), not penetrating the skin, but always using locations that are not qi points.[3],[4],[5]

If the essence of acupuncture is the magic of the qi points, but the same effect is produced when staying away from the qi points, the qi points aren’t doing anything.

This study did not use a sham acupuncture group. We have no reason to expect real acupuncture to provide more pain relief than sham acupuncture, so how should we use this information?

Should we have people providing fake acupuncture in the ED (Emergency Department)?

If so, how should we do this?

Since it is not the acupuncture, but the patient’s reaction to the ceremony of the placebo that appears to be providing the pain relief, how many different ways might we vary the treatment to improve the placebo effect?

Should we set up a fire walking pit?

What are the ethical concerns of using placebo medicine, when the placebo appears to provide similar, but safer, relief than real medicine?

What are the ethical concerns of using deception to treat patients?
 

Acupuncture versus intravenous morphine in the management of acute pain in the emergency department 1 with caption
 

Overall, 89 patients (29.3%) experienced minor adverse effects: 85 (56.6%) in morphine group and 4 (2.6%) in acupuncture group; the difference was signi ficant between the 2 groups (Table 3). The most frequent adverse effect was dizziness in the morphine group (42%) and needle breakage in the acupuncture group (2%). No major adverse effect was recorded during the study protocol. (See Table 4.)[6]

 

If we ignore the problems with this study and with the problem of lying to patients to make them feel better, can we expect research journals to look more like alternative medicine magazines with article titles like –

How to lie to patients, so that . . . .

What is the best scam to relieve pain?

How much integrity do we sacrifice?

Since the ED does not appear to be the source of the increase in opioid addiction, should we sacrifice any integrity in pursuit of placebo treatments?

We have an epidemic of opioid addiction because of excessive prescriptions for long-term pain.

The answer is not to try to create an epidemic of magical thinking.
 

This paper was also covered by –

Emergency Medicine Literature of Note

NEJM Journal Watch Emergency Medicine

Life in the Fast Lane

Science-Based Medicine

And thank you to Dr. Ryan Radecki of Emergency Medicine Literature of Note for providing me with a copy of the paper.

Footnotes:

[1] Placebo effect of medication cost in Parkinson disease: a randomized double-blind study.
Espay AJ, Norris MM, Eliassen JC, Dwivedi A, Smith MS, Banks C, Allendorfer JB, Lang AE, Fleck DE, Linke MJ, Szaflarski JP.
Neurology. 2015 Feb 24;84(8):794-802. doi: 10.1212/WNL.0000000000001282. Epub 2015 Jan 28.
PMID: 25632091

Free Full Text from PubMed Central

[2] Commercial features of placebo and therapeutic efficacy.
Waber RL, Shiv B, Carmon Z, Ariely D.
JAMA. 2008 Mar 5;299(9):1016-7. doi: 10.1001/jama.299.9.1016. No abstract available.
PMID: 18319411

Free Full Text in PDF format from Duke.edu

[3] Acupuncture for Menopausal Hot Flashes: A Randomized Trial.
Ee C, Xue C, Chondros P, Myers SP, French SD, Teede H, Pirotta M.
Ann Intern Med. 2016 Feb 2;164(3):146-54. doi: 10.7326/M15-1380. Epub 2016 Jan 19.
PMID: 26784863

Free Full Text in PDF format from carolinashealthcare.org

[4] A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain.
Cherkin DC, Sherman KJ, Avins AL, Erro JH, Ichikawa L, Barlow WE, Delaney K, Hawkes R, Hamilton L, Pressman A, Khalsa PS, Deyo RA.
Arch Intern Med. 2009 May 11;169(9):858-66. doi: 10.1001/archinternmed.2009.65.
PMID: 19433697

Free Full Text from PubMed Central

[5] Acupuncture for treatment of persistent arm pain due to repetitive use: a randomized controlled clinical trial.
Goldman RH, Stason WB, Park SK, Kim R, Schnyer RN, Davis RB, Legedza AT, Kaptchuk TJ.
Clin J Pain. 2008 Mar-Apr;24(3):211-8.
PMID: 18287826 [PubMed – indexed for MEDLINE]

[6] Acupuncture vs intravenous morphine in the management of acute pain in the ED.
Grissa MH, Baccouche H, Boubaker H, Beltaief K, Bzeouich N, Fredj N, Msolli MA, Boukef R, Bouida W, Nouira S.
Am J Emerg Med. 2016 Jul 20. pii: S0735-6757(16)30422-3. doi: 10.1016/j.ajem.2016.07.028. [Epub ahead of print]
PMID: 27475042

ClinicalTrials.gov page for this study.

Grissa, M., Baccouche, H., Boubaker, H., Beltaief, K., Bzeouich, N., Fredj, N., Msolli, M., Boukef, R., Bouida, W., & Nouira, S. (2016). Acupuncture vs intravenous morphine in the management of acute pain in the ED The American Journal of Emergency Medicine DOI: 10.1016/j.ajem.2016.07.028

Espay, A., Norris, M., Eliassen, J., Dwivedi, A., Smith, M., Banks, C., Allendorfer, J., Lang, A., Fleck, D., Linke, M., & Szaflarski, J. (2015). Placebo effect of medication cost in Parkinson disease: A randomized double-blind study Neurology, 84 (8), 794-802 DOI: 10.1212/WNL.0000000000001282

Waber RL, Shiv B, Carmon Z, Ariely D. (2008). Commercial Features of Placebo and Therapeutic Efficacy JAMA, 299 (9) DOI: 10.1001/jama.299.9.1016

Ee, C., Xue, C., Chondros, P., Myers, S., French, S., Teede, H., & Pirotta, M. (2016). Acupuncture for Menopausal Hot Flashes Annals of Internal Medicine, 164 (3) DOI: 10.7326/M15-1380

Cherkin, D., Sherman, K., Avins, A., Erro, J., Ichikawa, L., Barlow, W., Delaney, K., Hawkes, R., Hamilton, L., Pressman, A., Khalsa, P., & Deyo, R. (2009). A Randomized Trial Comparing Acupuncture, Simulated Acupuncture, and Usual Care for Chronic Low Back Pain Archives of Internal Medicine, 169 (9) DOI: 10.1001/archinternmed.2009.65

Goldman, R., Stason, W., Park, S., Kim, R., Schnyer, R., Davis, R., Legedza, A., & Kaptchuk, T. (2008). Acupuncture for Treatment of Persistent Arm Pain Due to Repetitive Use The Clinical Journal of Pain, 24 (3), 211-218 DOI: 10.1097/AJP.0b013e31815ec20f

.

Preventing Medication Errors from Gathering of Eagles

There are some interesting case studies in this presentation.[1]

1. Rule out seizures, patient is waking up, then becomes combative, medication given IM (IntraMuscularly), combativeness continues, combativeness resolves, everything seems OK.

Later, the empty medication is found to be morphine, not midazolam (Versed).

There is a problem in giving the wrong medication. We need to be more careful about what we give.

Just because the packaging looks the same does not mean the contents are even remotely similar.

2. Rule out hypoglycemia, medication given IV (IntraVenously), but it was sodium bicarbonate, rather than D50W (50% dextrose), then D50W was given.

Similar appearance does not mean the drug is the same.

3. Rule out extrapyramidal reaction to psychiatric medications, medication given IV, the medication was 10 mg morphine, medical command was contacted, the appropriate 50 mg of diphenhydramine (Benadryl) was given.

Appearances can be deceiving.

We trust what we think we see, but our brains jump to conclusions on insufficient evidence. We need to find ways to prevent us from misleading ourselves.

It is interesting that morphine is the drug accidentally given in two of the three cases. It is expected that the morphine and midazolam would be stored together. The diphenhydramine might be stored with the controlled substances to make it easier to treat histamine release from morphine administration. There is plenty of time to get diphenhydramine after noticing a reaction to morphine. I do not know of any cases of anaphylactic reactions to morphine. Keeping the diphenhydramine with the morphine does not improve patient safety. If the controlled substances need to be opened each time that diphenhydramine is given, that is probably not going to please the DEA (Drug Enforcement Administration, the controlled substances oversight organization in the US).

The good news is that the sodium bicarbonate is probably only going to result in some hyperventilation to blow off the CO2 (Carbon diOxide) produced by the breakdown of sodium bicarbonate.

The boxes do not look the same, but . . .

. . . the syringes do look alike (except for the identifying labels).

All the fear of giving too much morphine , but when 10 mg IV morphine is given to somebody who has no medical indication for morphine, there are no complications at all.

None.

10 mg morphine was harmless, but some doctors still worry about giving 2 mg without orders.

The medical education provided by some medical schools has some blatant gaps in the area of pain management and pharmacology.

Some medics still worry about giving 2 mg without orders.

The medical education provided by some paramedic schools also has some blatant gaps in the area of pain management and pharmacology.

Footnotes:

[1] Preventing Medication Errors
Gathering of Eagles 2012
Page with links to presentations

.

Not So Rapidly

Here is another Normal Sinus Rhythm post. My apologies for being late, again. The topic this week is unthemed, but I found the last post by Peter at Street Watch: Notes of a Paramedic to be a very useful topic – Drips, Slow Pushes, since this is one area where EMS is a font of misinformation. Read the rest of the NSR Blog posts at NSR Week 8.

Writing about D50W (50% Dextrose in Water) Peter mentions difficulty obtaining the product label for D50W. This is not really a surprise. First a bit about medication information, then information about D50W. The PDR (Physicians’ Desk Reference, some information from Wikipedia about the PDR) is paid for by the drug manufacturers. You will not find D50W, atropine, and some other commonly used medications. These medications are usually only available as generic medications and there is no incentive to pay to advertise a drug with little profit potential. The old way to get the product label, or package insert, for these medications was to ask the staff at the pharmacy. Extremely helpful people. When they open a case of these drugs, there is a label inside. The individual boxes, such as the D50W (pictured at the end), do not include the label. The side panel on the D50W instructs you to refer to the label – “usual dosage: see insert.” The insert is not in this box, but it was in the bigger box that this box came in. Not very helpful if you do not go to the pharmacy and ask the pharmacists about the product information.

One of the other examples of the way the manufacturers use the PDR as a sales catalog is that the medications are not arranged by type of drug, or alphabetically, or by any other method that would be useful in patient care. They are arranged by manufacturer. This certainly makes it easier for the sales rep to go from one drug to the next without having to flip past any of the other manufacturers products that may be safer, more effective, or both.

Anyway, this post isn’t to whine about how manufacturers make it difficult to find information about the drugs we use, but to provide ways for you to be able to find that information from more reliable sources. The FDA (Food and Drug Administration) is responsible for the accuracy of the information on the drug labels, such as drug safety alerts and black box warnings. Unfortunately, the FDA web site is not easy to navigate. For an example of what a black box warning is and looks like, here is a link to the label for Inapsine (droperidol) and for 2 generic versions of droperidol (1 & 2). The thin black border around the warning is the black box. Not very impressive, but there are a lot of restrictions on the use of a black boxed drug, not just those in the warning. A web site called Formulary Productions has a section for looking these up. Oddly enough it is called Black Box Warnings. They do not seem to feel the need to make you have to jump through hoops to find some important information.

So far, the more commonly used relative of droperidol, haloperidol (Haldol) has not received a black box, but it has received some alerts about misuse. For comparison, look at the label for Haldol. No black lined box around the warnings, but there still are warnings. If you notice that there are a bunch of things written before the fda part of the web address, I have been using DailyMed a part of the NLM (National Library of Medicine), which is a part to the NIH (National Institutes of Health). I have only recently been using this site, but it is very useful. Much easier to navigate than the FDA site. Unfortunately, they do not include all drugs, but they claim they are expanding their listings. DailyMed will give you the information in a form that they feel is easier to use than the label that the drug manufacturers provide to the FDA, but they also have a link to the FDA approved label, if you prefer that. Yes, the FDA only approves the label, the manufacturer writes it. In the comments, Baby J mentions a site – British National Formulary – that is not available in the US. Access is free, with free registration, to residents of the UK and the developing countries listed here.

What about D50W?

This is one place where DailyMed is very useful, but you still need to search through the available formulations of dextrose products to find the 50% dextrose by injection. There are about 90 products that a “dextrose” search will return. Of those some are listed as “dextrose injection,” “dextrose injection, solution,” and there are other possibilities. If you recognize the brand that you use (Baxter, Braun, and Hospira are the only ones listed), that may help to narrow the search. The one I found most appropriate was dextrose (Dextrose) injection, solution [Hospira, Inc.]. Dextrose is the most confusing drug to locate easily, because so many different formulations are available. I don’t think any other drug comes close, so don’t let this intimidate you. They do not seem to have a way to search from the NDC (National Drug Code Directory) number. The FDA’s National Drug Code Query page will identify the drug based on the NDC number, but that does not link to anything informative. If you have the NDC number, you probably already know the name of the medication, the manufacturer, and the packaging.

Another method of finding a drug label is to use a search engine, put in the generic name of the drug, the word “label,” and “pdf” for the format. Many labels are printed as pdfs so that they can be printed out to read. One of Peter’s complaints was that the type is very small. I agree, the older I get the harder it is to read things that used to be effortless. The advantage of reading these on line is the ability to adjust the font. On the top of the sidebar I have listed information about adjusting the font size to something that is comfortable. This may not work in all browsers and is something that may need to be adjusted each time you view the page. You can also go into the browser settings and mess around in there (Tools -> Content -> Font, in Firefox). With a pdf it is easier, since the size adjustment is at the top of the page. It is easy to store pdf files on your computer to return to later. They have their own search engine built in for searching within that document.

Below I have included some low quality pictures of the outside of the D50W box. As you can see, the manufacturer is not listed anywhere on the front of the box. The side panel that demonstrates how to put the syringe together is clearly only for those who have not seen Emergency!, where they pop the caps off simultaneously. Of course, it is more difficult with D50W than with epinephrine.

How do you give D50W? Do you dilute it?

D50W is given to people who have had their blood sugar drop and are experiencing confusion, that appears to be due to the low blood sugar. I was taught, and still use this method. I look for the largest vein that looks good for an IV site. The label recommends a small needle in a large vein. I prefer a large needle. If you have ever pushed D50W through a 20 gauge catheter, you understand part of the reason. It takes a lot of effort. If you have ever pushed D50W through a 22 gauge catheter, you are insane (or management). An additional reason to use a large bore catheter is that I want to aspirate blood back into the IV tubing, every 5 ml, to try to make sure that there is not leakage (extravasation) into the surrounding tissue. Highly concentrated dextrose, and 50% is very highly concentrated for injection, can cause death of the tissue (necrosis) in the area where it leaks out of the vein. This prevents the dextrose from getting to the cells where it is needed. As long as you can aspirate blood back every few ml, you can be pretty sure that the line is patent (intact). By stopping the drug push, drawing back blood into the IV tubing, and then resuming the push, there should be a lot of dilution taking effect. Using a large bore catheter makes aspiration of blood easier, because molasses is not the only thing difficult to move through a small catheter. Think about what you would use to infuse blood, it would not be a small needle.

Is it effective at diluting the dextrose?

I don’t know. This is the way I was taught and have always done it. I would like to hear from anyone who has looked into this. With medications that are slow push, giving a bit, pausing, coming back and giving some more, repeating as necessary, is one way to minimize side effects. Most side effects seem to be rate related (rate of administration, not heart rate, or any other rate). With many medications, I prefer to set the drip rate, push my initial dose into the IV tubing and observe. This avoids the problem of being tied to the syringe. Another method is to keep the syringe hooked up to the tubing, pushing a bit more every 15/30/60 seconds, depending on what the medication is. This does have the potential for accidentally giving the entire syring in one dose. If you limit this to drugs that are on the less dangerous side, where you are more concerned about side effects that are uncomfortable, not side effects that are life threatening, then this can be used safely. JCAHO would never approve, but I have never had a problem. It can help to tape the syringe to the IV tubing, so that they do not become separated.

An amusing example of misunderstanding what rate of administration means was something I first observed when I was still a basic EMT. It was obvious that the person giving the medication had never thought about what was being done. This was in a big city level 1 trauma center. I’m taking the patient to another facility (I do not remember any of the details), the nurse wants to give some morphine to the patient before transport. This is something that is good. The nurse clamped the IV tubing to prevent it from flowing while the morphine was being given. Then the nurse held the syringe for about 2 minutes, pushing v e r y slowly for the whole time. My forearm was becoming sore, just watching this. Immediately after this, the nurse grabs a syringe of saline and pushes the saline to flush the line.

WTF?

The majority, if not all, of the morphine was still in the IV tubing. The nurse spent 2 minutes pushing the morphine into the IV tubing, just pushing out the IV solution. Then slammed the drug into the patient with a flush that served no purpose, other than to demonstrate a lack of understanding of drug administration. The good thing for the patient was that the morphine dose was probably only 2 mg. So the side effects would be minimal with rapid administration. The bad thing for the patient was that morphine dose was probably only 2 mg. So the benefit of treatment is as unlikely to produce benefit as it is unlikely to produce side effects.

Pushing drugs like morphine, fentanyl, midazolam, lorazepam, and others where the dose is in a small volume, often only about 1 ml, makes it almost pointless trying to hang a bag to dilute the drug, but pushing the dose into the IV tubing – if you can control the rate – is not a bad idea. The volume is small enough that all of the medication remains in the tubing. You need some way of marking where the medication begins. Some medications are different in appearance and this is easy. Others are indistinguishable from the IV fluid, so on method is to use a tiny air bubble to mark the beginning of the medication. No, a small air bubble is not going to be harmful, no matter how many alarms it would set off with an infusion pump.

That is more than enough for one post.

Up to a Maximum of X Times vs. Titration

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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Accidental Extra Strength Morphine

The FDA has notified people that ETHEX Corporation is recalling a single lot of 60 mg extended release morphine tablets. They are concerned about the consequences of OD (OverDose).

First thought to come to mind – the patient might actually experience pain relief with a more appropriate dose, since so many prescribers are more concerned about OD than about effective pain management.

Dr. Marcia Angell once wrote this about pain management:

I can’t think of any other area in medicine in which such an extravagant concern for side effects so drastically limits treatment.[1]

A couple of interesting words here:

Extravagant.

1 a obsolete : strange, curious
b archaic : wandering

2 a: exceeding the limits of reason or necessity
b: lacking in moderation, balance, and restraint
c: extremely or excessively elaborate

3 a: spending much more than necessary
b: profuse, lavish

4: extremely or unreasonably high in price

synonyms see excessive

Drastically.

1 : acting rapidly or violently

2 : extreme in effect or action : severe

Dr. Angell makes it sound so extreme. Is it?

Let’s look at an example. These are patients taking a daily does of 60 mg morphine, at least once a day, so this is a relevant example.

If you’re treating patients who have used opiates in the past or who use them chronically to control pain, on the other hand, respiratory depression is not as important. Dr. Jacobson said that these patients often become tolerant to the drugs’ side effects. As a result, he added, these patients are typically unaffected by the drugs’ tendency to depress respiration.

To give an example, Dr. Preodor recalled a patient who was receiving 10 mg of morphine per hour but mistakenly received 250 mg in just over an hour. A sitter monitored the patient through the night to make sure she suffered no ill effects, and the patient was fine. (Her main comment was that she had never slept better.)

While the case was extreme, it shows that patients who are used to opiates and their side effects can handle much higher doses of the drugs without many of the negative side effects. If the patient was unaccustomed to opiates, Dr. Preodor said, the incident could have turned out badly.[2]

There are only a few good articles about pain management, articles that dissect the complications in treating patients, both legal and medical. This is one of the best. Read the entire article. The links are also worth reading.

So, is this something that should be treated with large doses of panic and naloxone (Narcan)?

Naloxone should be titrated to effect, assuming there is any need at all.

Is there respiratory depression?

Are we treating the dose or the patient?

The FDA notice is useful information to have, but unbalanced and extreme. I believe that what Dr. Angell wrote back in 1982 about the extreme responses to pain management is still true. I would add one area, aside from pain management, to the extreme concern for side effects at the expense of the patient – sedation.

Footnotes:

^ 1 The quality of mercy.
Angell M.
N Engl J Med. 1982 Jan 14;306(2):98-9. No abstract available.
PMID: 7053494 [PubMed – indexed for MEDLINE]

^ 2 Avoiding trouble when using opiates to treat patient pain.
June 2003 ACP Observer, copyright © 2003 by the American College of Physicians.
By Jason van Steenburgh
Article
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You just don’t understand my chronic pain!

Nurse K at Crass-Pollination (in her sidebar, read the definition) writes Saturday morning CRAYZEE!!!!!!!!!!!!!! about a response to an old post of hers What do you do when you start to feel like a drug dealer at work?

First, Nurse K works in the ED (Emergency Department).

Let’s think about that. Chronic pain is something that is long term, so it should not generally result in a trip to the ED. Emergencies are the kind of injuries or illnesses that lead to acute pain. There should be a method, for the patient with chronic pain, to deal with break-through pain. The method should not be to go to the ED. The method should not be to procrastinate on refilling a prescription, until the weekend, so that your doctor is not available. This is manipulative and self-destructive.

The problem patients Nurse K describes are patients who are abusing the system. Legitimate chronic pain patients should be just as upset with these patients as Nurse K is.

The abusers of the system only make it more difficult for those with legitimate chronic pain to receive appropriate pain management.

Legitimate chronic pain patients should hate these people who make a mockery of genuine chronic pain. Those who put on an act to receive their pain medications.

How we deal with pain tells a lot about who we are.

I’ve had patients with extremely bad injuries. Injuries so bad that I feel very uncomfortable not giving them something for pain.

When the patient says, “I’ve had worse,” and I doubt that I have; or “I’ll wait until I really need something,” and I’m hoping that will be sometime before the surgeon starts cutting; or “I used to abuse drugs and nothing is worth living like that again;” or is lying in bed with a heart rate of 150, pale and sweaty, but discouraging large enough doses to make a significant dent in the level of pain; with that perspective, we are able to see the range of response to pain.

What is 10/10 pain?

For most people, burns seem to be the worst kind of pain. Imagine a red hot frying pan.

Now, reach out and touch the tip of your finger to the frying pan for half a second. What would happen if this were done for real? You have a burn. It hurts. Few people would repeat that experiment any time soon.

Now, imagine having your hand being held against the red hot frying pan, the entire palm of your hand, it doesn’t matter which one.

Think about that pain for a while.

If you have any kind of imagination, and you do not have a psychological illness that isolates you from this kind of empathy, then this should make you uncomfortable, at least.

The pain scale is not from This Is Spinal Tap. It does not go to 11.

Work on a burn unit. These patients have experienced this kind of pain, but now are experiencing severe chronic pain similar to the acute pain they experienced with the initial burn. This is not the only kind of acute or chronic pain worth treating. That is not what I am stating.

I am trying to give an idea of what debilitating pain is.

Fibromyalgia is a way to give a name to a much lower level of pain. If it has a name and a diagnosis, well then the drug companies can sell you a treatment for it. Pregabalin (Lyrica) an anti-seizure, neuropathic pain medication is approved for treatment of fibromyalgia. Here is an interesting view of the effect of pregabalin.

In a study of recreational users (N=15) of sedative/hypnotic drugs, including
alcohol, LYRICA (450mg, single dose) received subjective ratings of “good drug
effect,” “high” and “liking” to a degree that was similar to diazepam (30mg,
single dose).

Pregabalin does not have any studies that show addiction to it. It is interesting that recreational users of drugs would rate it as similar to benzodiazepines (part of the class of drugs these drug users desired). Pregabalin, the only drug approved for the treatment of fibromyalgia, is not an opioid (a natural or synthetic derivative of the opium poppy, related to morphine). The idea of using opioids to treat fibromyalgia is not one the FDA appears to be endorsing.

I am very liberal with pain medicine (when OLMC allows it) and I do not take pain lightly.

Encouraging people to lie there, and to give in to the pain, is just the wrong approach. The more you give in to the pain, the more pain medicine you need, the more you become dependent on pain medication, the less you are able to take care of yourself, the more you become a victim of your own response to the pain.

You become your own victim – not a victim of the chronic pain.

This is tragic. The epitome of tragedy, Hamlet, said –

there is nothing
either good or bad, but thinking makes it so: to me
it is a prison.


O God, I could be bounded in a nut shell and count
myself a king of infinite space, were it not that I
have bad dreams.


That last line confuses many people, not having the ability to understand Hamlet’s “bad dreams,” but it would never work if he were to say, were it not that I have fibromyalgia.”

Hamlet’s dead father would come to him in his dreams and tell him that he was murdered by Hamlet’s uncle, who is now also Hamlet’s step father and the new King. Very unhappy times for Hamlet and this is just the beginning!

Hamlet may have been the prince of despair, the Shakespearean character most likely to whine, but fibromyalgia would never have worked for him.

Maybe it was King Lear with his prove to me that you love me, or Othello with his willingness to let Iago convince him that his wife was fooling around, but Shakespeare knew how to write tragedy. All of these responses to adversity prove to be tragic. And fatal. And whiny.

Was Nurse K being inappropriate?

Not at all. Chronic pain patients would be better off listening to her, than those who say just lie there and suffer, but do it dramatically.

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How EMS Manages Pain

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.comThe 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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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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